Elan D. Cohen

Assessing the Feasibility of the American College of Surgeons' Benchmarks for the Triage of Trauma Patients

OBJECTIVE To test the feasibility of accomplishing the American College of Surgeons Committee on Trauma benchmarks of less than 5% undertriage (treatment of patients with moderate to severe injuries at nontrauma centers [NTCs]) and less than 50% overtriage (transfer of patients with minor injuries to trauma centers [TCs]) given current practice patterns by describing transfer patterns for patients taken initially to NTCs and estimating volume shifts and potential lives saved if full implementation were to occur. DESIGN, SETTING, AND PATIENTS Retrospective cohort study of adult trauma patients initially evaluated at NTCs in Pennsylvania (between April 1, 2001, and March 31, 2005). We used published estimates of mortality risk reduction associated with treatment at TCs. MAIN OUTCOME MEASURES Undertriage and overtriage rates, estimated patient volume shifts, and number of lives saved. RESULTS A total of 93,880 adult trauma patients were initially evaluated at NTCs in Pennsylvania between 2001 and 2005. Undertriage was 69%; overtriage was 53%. Achieving less than 5% undertriage would require the transfer of 18,945 patients per year, a 5-fold increase from current practice (3650 transfers per year). Given an absolute mortality risk reduction of 1.9% for patients with moderate to severe injuries treated at TCs, this change in practice would save 99 potential lives per year or would require 191 transfers per year to save 1 potential life. CONCLUSIONS Given current practice patterns, American College of Surgeons Committee on Trauma recommendations for the regionalization of trauma patients may not be feasible. To achieve 5% undertriage, TCs must increase their capacity 5-fold, physicians at NTCs must increase their capacity to discriminate between moderate to severe and other injuries, or the guidelines must be modified.

Addressing health literacy through clear health communication: A training program for internal medicine residents

OBJECTIVE To develop, pilot, and test the effectiveness of a clear health communication curriculum to improve resident knowledge, attitudes, and skills regarding health literacy. METHODS Thirty-one internal medicine residents participated in a small group curriculum that included didactic teaching, practice with a standardized patient, and individualized feedback on videotaped encounters with real patients. Outcomes were assessed using a pre-post survey and a communication skills checklist. RESULTS Mean knowledge scores increased significantly from 60.3% to 77.6% (p<0.001). Residents also reported increased familiarity with the concept of health literacy (mean response 3.2 vs. 4.5 on a 5 point scale), importance placed on health literacy (4.2 vs. 4.9), frequency of considering health literacy in patient care (3.3 vs. 4.0), and confidence in communicating with low literacy patients (3.3 vs. 4.1) (all p<0.001). Use of plain language increased significantly from 33% to 86% (p=0.023). There were nonsignificant increases in the use of teach-back (0-36%, p=0.116) and encouraging questions (0-14%, p=0.502). CONCLUSION Training in clear health communication improves resident knowledge, attitudes, and skills regarding health literacy. PRACTICE IMPLICATIONS The increased use of clear health communication techniques can significantly improve the care and outcomes of vulnerable patients with limited health literacy.

Psychometric Properties of the Mentor Role Instrument when Used in an Academic Medicine Setting

The Ragins and McFarlin Mentor Role Instrument (RMMRI) was originally developed to measure perceptions of mentoring relationships in research and development organizations. The current study was designed to evaluate the RMMRIs reliability and validity when the instrument was administered to clinical and translational science trainees at an academic medical center. The 33‐item RMMRI was administered prospectively to a cohort of 141 trainees at the University of Pittsburgh in 2007–2008. Likert‐scale items focused on perceptions of five mentoring roles in the career dimension (sponsor, coach, protector, challenger, and promoter) and six mentoring roles in the psychosocial dimension (friend, social associate, parent, role model, counselor, and acceptor). Outcome items included overall perceptions of mentoring satisfaction and effectiveness. Of 141 trainees, 53% were male, 66% were white, 22% were Asian, and 59% were medical doctors. Mean age was 32 years. Analyses showed strong within‐factor inter‐item correlations (Pearson Coefficients of 0.57–0.93); strong internal consistency (Cronbach alphas of 0.82–0.97); confirmatory factorial validity, as demonstrated by confirmatory factor analysis of the two mentoring dimensions, 11 mentoring roles, and 33 RMMRI items; and concurrent validity, as demonstrated by strong correlations (Pearson Coefficients of 0.56–0.71) between mentoring dimensions, satisfaction, and effectiveness. This article concludes that the RMMRI shows reliability and validity in capturing the multidimensional nature of mentoring when administered to clinical and translational science trainees in the academic setting. Clin Trans Sci 2010; Volume 3: 104–108

Racial and ethnic differences in contraceptive use among women who desire no future children, 2006–2010 National Survey of Family Growth

OBJECTIVE To evaluate racial/ethnic differences in contraceptive use among women who do not desire future pregnancy. STUDY DESIGN We used the 2006-2010 National Survey of Family Growth to examine the associations between race/ethnicity and 1) use of any contraceptive method at last heterosexual intercourse and 2) effectiveness of contraceptive method used among women who stated that they did not desire any (more) children. We conducted multivariable logistic regression to assess the independent effect of race/ethnicity on these outcomes, adjusting for socio-demographic factors, reproductive characteristics, and indicators of healthcare access and utilization. RESULTS The study sample consisted of 2900 women, aged 15-44 years. The vast majority of women (91.2%) used contraception at last sex, although this varied significantly by race/ethnicity (p<.01). In the fully adjusted model controlling for demographic and reproductive characteristics as well as healthcare access, compared to whites, black women were significantly less likely to use any contraception at last sex (OR: 0.43; 95% CI: 0.27-0.73), while there was no significant difference for Hispanic women (OR: 0.95; 95% CI: 0.52-1.72). Among women who used a method at last sex, the type of contraceptive method varied significantly by race/ethnicity in bivariate analysis (p<.01), although most women (59%) used a highly effective method. In the fully adjusted model, racial/ethnic differences were no longer significant. CONCLUSIONS In this nationally representative cohort of women who report that they do not desire (more) children, black women were significantly less likely than white women to use any contraception at last intercourse; this difference did not appear to be due to differential access to health care. IMPLICATIONS Significant racial/ethnic differences exist in contraceptive use among women who have completed childbearing, which do not appear to be explained by differential socioeconomic status, reproductive characteristics or utilization of healthcare. Other factors, including social mobility and locus of reproductive control, that may contribute to these variations should be further explored.

Clinical Decision Support to Promote Safe Prescribing to Women of Reproductive Age: A Cluster-Randomized Trial

ABSTRACTBACKGROUNDPotentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.OBJECTIVETo evaluate whether computerized clinical decision support (CDS) can increase primary care providers’ (PCPs’) provision of family planning services when prescribing potentially teratogenic medications.DESIGNCluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.PARTICIPANTS/INTERVENTIONSForty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The ‘simple’ CDS provided a cautionary alert; the ‘multifaceted’ CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.MAIN MEASURESWe assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.KEY RESULTSBoth CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction.CONCLUSIONSCDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

Long-term central venous access in pediatric patients at high risk: conventional versus antibiotic-impregnated catheters.

PURPOSE To study selective use of antibiotic-impregnated catheters in children at increased risk of venous catheter-related infections (CRIs). MATERIALS AND METHODS From December 2008 to June 2009, 428 peripherally inserted central catheters (PICCs) were placed by the interventional radiology service of a large metropolitan childrens hospital. This retrospective study analyzed demographic and outcome data for the 125 patients in this group at high risk for venous CRI. Patients at high risk were those with active systemic infection, previous complicated central venous access, intensive care unit (ICU) admission, intestinal failure, transplantation, complex congenital heart disease, or renal failure. Patients (age, 7.6 y ± 7.0; 73 male and 52 female) received a conventional or antibiotic-impregnated PICC, with 17 receiving more than one catheter. RESULTS Of the 146 of 428 qualifying patient encounters (34%), 53 patients received an antibiotic-impregnated PICC and 93 received a conventional PICC, representing 5,080 total catheter-days (CDs). The rates of CRIs per 1,000 CDs, including catheter exit site infections and catheter-related bloodstream infections, were 0.86 for antibiotic-impregnated PICCs and 5.5 for conventional PICCs (P = .036). A propensity-based model predicts 15-fold greater infection-free survival over the lifetime of the catheter in patients who receive an antibiotic-impregnated PICC (P < .001). Antibiotic-impregnated PICC recipients with active infection or ICU admission at the time of insertion had no catheter-associated infections, compared with 3.42 and 9.46 infections per 1,000 CDs, respectively, for patients who received conventional PICCs. Patients with intestinal failure had 1.49 and 10 infections per 1,000 CDs with antibiotic-impregnated versus conventional PICCs, respectively. CONCLUSIONS Antibiotic-impregnated long-term PICCs significantly improve infection-free catheter survival in pediatric patients at high risk.

Impact of seasonal flux on 25‐hydroxyvitamin D and bone turnover in pre‐ and early pubertal youth

Seasonal fluxes in 25‐hydroxyvitamin D (25(OH)D) in children can affect bone turnover, and in turn potentially affect bone accrual and peak bone mass. The aim of this study was to examine the effect of seasonal flux on the association among 25(OH)D, parathyroid hormone (PTH) and markers of bone turnover in pre‐ and early pubertal black children and white children.

A Shortened Version of the Clinical Research Appraisal Inventory: CRAI-12

Purpose The original Clinical Research Appraisal Inventory (CRAI), which assesses the self-confidence of trainees in performing different aspects of clinical research, comprises 92 items. Completing the lengthy CRAI is time-consuming and represents a considerable burden to respondents, yet the CRAI provides useful data for evaluating research training programs. The purpose of this study is to develop a shortened version of the CRAI and to test its validity and reliability. Method Trainees in clinical research degree and career development programs at the University of Pittsburgh’s Institute for Clinical Research Education completed the 92-item CRAI between 2007 and 2012, inclusive. The authors conducted, first, exploratory factor analysis on a training dataset (2007–2010) to reduce the number of items and, then, confirmatory factor analyses on a testing dataset (2011–2012) to test the psychometric properties of the shortened version. Results Of 546 trainees, 394 (72%) provided study data. Exploratory factor analysis revealed six distinct factors, and confirmatory factor analysis identified the two items with the highest loadings per factor, for a total of 12 items. Cronbach alpha for the six new factors ranged from 0.80 to 0.94. Factors in the 12-item CRAI were strongly and significantly associated with factors in the 92-item CRAI; correlations ranged from 0.82 to0.96 (P < .001 for each). Conclusions The 12-item CRAI is faster and less burdensome to complete but retains the strong psychometric properties of the original CRAI.

Brief motivational enhancement intervention to prevent or reduce postpartum alcohol use: A single-blinded, randomized controlled effectiveness trial

AIMS The aim of this study is to assess the effect of brief motivational enhancement intervention postpartum alcohol use. DESIGN This study is a single-blinded, randomized controlled effectiveness trial in which pregnant women were assigned to receive usual care or up to 5 face-to-face brief motivational enhancement sessions lasting 10-30 minutes each and occurring at study enrollment, 4 and 8 weeks after enrollment, 32 weeks of gestation, and 6 weeks postpartum. SETTING The setting is in a large, urban, obstetrics clinic. PARTICIPANTS Participants were women who were ≥ 18 years old, <20 weeks of gestation, and consumed alcohol during pregnancy. Of 3438 women screened, 330 eligible women were assigned to usual care (n = 165) or intervention (n=165). Due to missing data, we analyzed 125 in the intervention group and 126 in the usual care group. MEASUREMENTS The measurements were the proportion of women with any alcohol use and the number of drinks per day, reported via follow-up telephone interviews at 4 and 8 weeks after enrollment, 32 weeks of gestation, and 6 weeks, 6 months, and 12 months postpartum. FINDINGS In random effects models adjusted for confounders, the intervention group was less likely to use any alcohol (odds ratio 0.50; 95% confidence interval [CI], 0.23-1.09; P=0.08) and consumed fewer drinks per day (coefficient -0.11; 95% CI -0.23-0.01; P=0.07) than, the usual care group in the postpartum period but these differences were non-significant. Missing data during the prenatal period prevented us from modeling prenatal alcohol use. CONCLUSIONS Brief motivational enhancement intervention delivered in an obstetrical outpatient setting did not conclusively decrease alcohol use during the postpartum period.

Measurement of Social Capital among Clinical Research Trainees

While physical and human capital are established as important predictors of success among early‐career clinical investigators, less is known about the role of social capital. The authors aimed to develop a brief scale to assess social capital in this population and test its reliability and validity. A three‐item assessment was developed based on a conceptual framework and measures of social capital from other fields and was administered to 414 clinical research trainees at the University of Pittsburgh in 2007–2012. The measure exhibited good internal consistency reliability (α = 0.71) and a normal distribution. On a 10‐point scale, mean social capital was 6.4 (SD = 1.7). Social capital was significantly associated with 7 of the 9 expected constructs: sex, age, confidence in research skills, work‐related motivation, burnout, and social support. Exploratory multivariable regression analysis demonstrated that social capital was most strongly associated with higher research confidence (β = 0.35, p < 0.001), higher extrinsic motivation (β = 0.50, p = 0.003), and lower burnout (ptrend = 0.02). This three‐item scale measures social capital in this population with adequate internal consistency reliability, face validity, and construct validity. This brief assessment provides a tool that may be valuable to benchmark social capital of clinical research trainees and to better contextualize programmatic and trainee outcomes.