Imad Maatouk

Effects of Peyton's Four-Step Approach on Objective Performance Measures in Technical Skills Training: A Controlled Trial

Background: Although skills-lab training is widely used for training undergraduates in technical procedures, the way in which clinical skills are to be used and instructed remains a matter of debate. Purpose: We conducted a randomized controlled trial to evaluate the learning outcome of two different instructional approaches in the context of acquiring procedural–technical skills. Methods: Volunteer 2nd- and 3rd-year medical students were randomly assigned to an intervention group receiving instruction according to Peytons Four-Step Approach (IG; n = 17) or to a control group receiving standard instruction (CG; n = 17). Both groups were taught gastric-tube insertion using a manikin. Following each of the two forms of instruction, participants’ first independent gastric-tube insertions were video recorded and scored by two independent video assessors using binary checklists and global rating forms. The time required for each instructional approach and for the first independent performance of the skill was measured. Results: A total of 34 students agreed to participate in the trial. There were no statistically significant group differences with regard to age, sex, completed education in a medical profession, or completed medical clerkships. The groups did not differ in terms of correct stepwise performance of the procedure as assessed by a binary checklist (p < .802). However, ratings based on global rating scales assessing professionalism and accompanying patient-doctor communication proved significantly better in IG (both ps < .001). The length of the different instructional approaches did not differ significantly between the two groups (IG: 605 ± 65 s; CG: 572 ± 79 s; p < .122), but the time needed for the first independent performance of gastric-tube placement on the manikin was significantly shorter in IG (IG: 168 ± 30 s; CG: 242 ± 53 s; p < .001). Conclusions: Peytons Four-Step Approach is superior to standard instruction with respect to professionalism and accompanying doctor–patient communication and leads to faster performance when trainees perform the learned skill for the first time.

Longitudinal predictors of health-related quality of life in middle-aged and older adults with hypertension: results of a population-based study.

Objective: The aim of the study was to assess the longitudinal association between cardiovascular risk factors including albuminuria and other variables (e.g. awareness of hypertension, number of types of antihypertensive drugs, comorbidity), and health-related quality of life (HRQOL) in a large cohort of patients with hypertension, over a follow-up period of 5 years. Methods: Nine thousand nine hundred and fifty-three participants of the ESTHER (Epidemiologische Studie zu Chancen der Verhütung, Früherkennung und optimierten Therapie chronischer Erkrankungen) study – a population-based cohort study of middle-aged and older adults aged 50–74 years at baseline – were recruited by general practitioners (GPs) in 2000–2002 and included in the follow-up (2005–2007). HRQOL at baseline and follow-up was measured using the Short-Form General Health Survey (SF-12). Mental component scores (MCS) and physical component scores (PCS) were calculated. Multiple linear regression models were used to determine longitudinal predictors of HRQOL at follow-up. Results: Four thousand, two hundred and three patients with hypertension (98.2%) responded to the SF-12 both at baseline and after 5 years and were therefore included in the study. Smoking status, BMI, diabetes, macroalbuminuria, comorbid diseases, history of depression, and lower HRQOL at baseline predicted lower PCS at the 5-year follow-up. Lower MCS after 5 years was predicted by smoking status, dyslipidaemia, a reported history of depression, and HRQOL at baseline. No significant association was detected between awareness of hypertension and any HRQOL component score after 5 years. Conclusions: Macroalbuminuria and other variables related to increased cardiovascular risk have a negative impact on PCS. Suggestions of a link of treatment and awareness of hypertension with HRQOL from previous cross-sectional studies are not supported by our longitudinal findings.

Reliable integrative assessment of health care needs in elderly persons: the INTERMED for the Elderly (IM-E).

OBJECTIVE With the increasing prevalence of multiple conditions in older age, the high prevalence of mental disorders, and the many social challenges facing elderly people, a high-risk patient group in need of interdisciplinary (biological, psychological, and social) care is emerging. The INTERMED interview is an integrative assessment method that identifies patients with complex health care needs. The aim of this study was to develop and evaluate the INTERMED for the Elderly (IM-E), specifically for use in populations of elderly persons. METHODS In focus groups conducted with the authors of the original INTERMED, the variables and anchor points that had to be adjusted to the needs and situation of the elderly and to the demands of a population-based study were discussed and altered. The final version of the IM-E was conducted with 42 elderly persons. Participants were doubly scored by two trained raters; the interrater reliability [intraclass correlation coefficient (ICC) (2,1)] was calculated. RESULTS The IM-E was well accepted by the elderly persons interviewed. ICCs for the various domains of the IM-E ranged between .87 and .95, while the ICC for the sum score was .95. Regarding the cutoff point of 20/21 for patients with complex health care needs, a κ of .75 was achieved. CONCLUSIONS The IM-E is a reliable integrative assessment instrument. It is well suited for epidemiological settings to adequately describe the percentage of elderly patients with complex health care needs. In clinical settings, it can be used to identify elderly patients in need of interdisciplinary care.

Significance and costs of complex biopsychosocial health care needs in elderly people: results of a population-based study.

Objective To improve health care for the elderly, a consideration of biopsychosocial health care needs may be of particular importance—especially because of the prevalence of multiple conditions, mental disorders, and social challenges facing elderly people. The aim of the study was to investigate significance and costs of biopsychosocial health care needs in elderly people. Methods Data were derived from the 8-year follow-up of the ESTHER study—a German epidemiological study in the elderly population. A total of 3124 participants aged 57 to 84 years were visited at home by trained medical doctors. Biopsychosocial health care needs were assessed using the INTERMED for the Elderly (IM-E) interview. Health-related quality of life (HRQOL) was measured by the 12-Item Short-Form Health Survey, and psychosomatic burden was measured by the Patient Health Questionnaire. Results The IM-E correlated with decreased mental (mental component score: r = −0.38, p < .0001) and physical HRQOL (physical component score: r = −0.45, p < .0001), increased depression severity (r = 0.53, p < .0001), and costs (R = 0.41, p < .0001). The proportion of the participants who had an IM-E score of at least 21 was 8.2%; according to previous studies, they were classified as complex patients (having complex biopsychosocial health care needs). Complex patients showed a highly reduced HRQOL compared with participants without complex health care needs (mental component score: 37.0 [10.8] versus 48.7 [8.8]; physical component score: 33.0 [9.1] versus 41.6 [9.5]). Mean health care costs per 3 months of complex patients were strongly increased (1651.1 &OV0556; [3192.2] versus 764.5 &OV0556; [1868.4]). Conclusions Complex biopsychosocial health care needs are strongly associated with adverse health outcomes in elderly people. It should be evaluated if interdisciplinary treatment plans would improve the health outcomes for complex patients.

Association of hypertension with depression and generalized anxiety symptoms in a large population-based sample of older adults.

Objective: The aim of the study was to assess the association of hypertension and symptoms of depression and generalized anxiety in a large cohort of elderly people. Methods: Data were derived from the 8-year follow-up (2008–2010) of the epidemiological ESTHER-cohort study. A total of 3124 randomly chosen participants aged 57–84 were visited at their homes by trained study doctors. General practitioner based diagnosis, self-reported status of hypertension, medication, and blood pressure measurement were considered to define the existence of hypertension. Depression and general anxiety severity were assessed using validated questionnaires. Logistic regression analyses were performed to determine cross-sectional associations between hypertension and clinically significant symptoms of depression (CSD) and generalized anxiety. Well known lifestyle risk factors for hypertension such as obesity were included in multivariate cross-sectional analyses. Results: Hypertension was prevalent in 1659 participants [53.1%; 95% confidence interval (CI) = (51.3; 54.9)]. CSD was detected in 163 participants [5.2%; 95%-CI = (4.4; 6.0)]. Symptoms of generalized anxiety were found in 434 participants [13.9%; 95%-CI = (12.7; 15.1)]. Patients with CSD showed significantly higher odds of being hypertensive [odds ratio (OR) = 1.76; 95%-CI = (1.14; 2.74)]. Participants with symptoms of generalized anxiety were found to have no higher odds for a hypertension diagnosis [OR = 1.1; 95%-CI = (0.85; 1.44)]. Overweight [OR = 1.86; 95%-CI = (1.53; 2.25)] as well as obesity [OR = 3.58; 95%-CI = (2.84; 4.52)] was significantly associated with hypertension. Conclusion: CSD appear to be related to hypertension in elderly adults. No association was found between symptoms of generalized anxiety and hypertension.

Peyton's four-step approach: differential effects of single instructional steps on procedural and memory performance - a clarification study.

Background Although Peyton’s four-step approach is a widely used method for skills-lab training in undergraduate medical education and has been shown to be more effective than standard instruction, it is unclear whether its superiority can be attributed to a specific single step. Purpose We conducted a randomized controlled trial to investigate the differential learning outcomes of the separate steps of Peyton’s four-step approach. Methods Volunteer medical students were randomly assigned to four different groups. Step-1 group received Peyton’s Step 1, Step-2 group received Peyton’s Steps 1 and 2, Step-3 group received Peyton’s Steps 1, 2, and 3, and Step-3mod group received Peyton’s Steps 1 and 2, followed by a repetition of Step 2. Following the training, the first independent performance of a central venous catheter (CVC) insertion using a manikin was video-recorded and scored by independent video assessors using binary checklists. The day after the training, memory performance during delayed recall was assessed with an incidental free recall test. Results A total of 97 participants agreed to participate in the trial. There were no statistically significant group differences with regard to age, sex, completed education in a medical profession, completed medical clerkships, preliminary memory tests, or self-efficacy ratings. Regarding checklist ratings, Step-2 group showed a superior first independent performance of CVC placement compared to Step-1 group (P<0.001), and Step-3 group showed a superior performance to Step-2 group (P<0.009), while Step-2 group and Step-3mod group did not differ (P=0.055). The findings were similar in the incidental free recall test. Conclusion Our study identified Peyton’s Step 3 as being the most crucial part within Peyton’s four-step approach, contributing significantly more to learning success than the previous steps and reaching beyond the benefit of a mere repetition of skills demonstration.

Control preferences in treatment decisions among older adults — Results of a large population-based study

OBJECTIVE Older adults appear to be a specifically vulnerable group that could benefit considerably from the assessment of their decision-making preferences. The aim of this study was to estimate prevalence rates and to explore characteristics of control preferences in a population-based sample of older adults. METHODS Data was derived from the 8-year follow-up of the ESTHER study - a German epidemiological study in the elderly population. n=3124 participants ages 57 to 84 were visited at home by trained medical doctors for a comprehensive assessment regarding various aspects of their life. The German version of the Control Preferences Scale (CPS) was used to assess decision-making. RESULTS Most of the participants reported a preference for an active role in the decision-making process (46%, 95% CI [44.3; 47.9]), while 30.0% [28.4; 31.5] preferred a collaborative role, and 23.9% [22.4; 25.5] a passive role. Participants aged ≤65years preferred a more passive role in decision-making compared to persons aged <65years. Participants with clinically significant depression symptoms (CSD) preferred significantly more often a passive role compared to those without CSD. Similarly, multimorbid patients preferred a passive role compared to people with none or one chronic disease. Conversely, in groups with active or collaborative control preferences the morbidity index was lower compared to the group with passive control preferences. CONCLUSION Results indicate that physical and mental health in the elderly are associated with the preference role. It should, however, be investigated whether multimorbidity or mental diseases influence the treatment preference of older adults.

Healthy ageing at work— Efficacy of group interventions on the mental health of nurses aged 45 and older: Results of a randomised, controlled trial

Objective This multicentre, randomised controlled trial (RCT) aimed to evaluate the efficacy of a small-group intervention promoting successful ageing at work in older nurses (aged ≥45). Method A sample of 115 nurses aged ≥45 from 4 trial sites in Germany were randomly assigned to either the intervention group (IG), that received a small-group intervention of seven weekly sessions of 120 min with a booster session after six weeks or to a wait-list control condition (WLC). Outcomes were measured via validated self-report questionnaires at baseline (T1) and at post-treatment (T2). Primary outcomes were mental health-related well-being and mental health-related quality of life (QOL). The secondary outcomes included mental health-related and work-related measures. Results The intention to treat (ITT) analysis showed significant positive effects of the intervention on mental health. A significant small effect (d = 0.3) in favour of the IG was found for psychological health-related quality of life. Positive small effects (d = 0.24 to d = 0.31) were also found for work related mental strain. Conclusions Our small-group intervention based on a theory of successful ageing for nurses aged ≥45 was found to be effective with regard to improvements of psychological health related quality of life and other mental health-related outcomes. Thus, our study shows that the ageing workforce can be reached through specifically designed preventive interventions. The components of our intervention could be easily adapted to the belongings of other professions. Our results suggest that these components should be evaluated in various settings outside the healthcare sector.

Physical examination skills training: Faculty staff vs. patient instructor feedback—A controlled trial

Background Standardized patients are widely used in training of medical students, both in teaching and assessment. They also frequently lead complete training sessions delivering physical examination skills without the aid of faculty teaching staff–acting as “patient instructors” (PIs). An important part of this training is their ability to provide detailed structured feedback to students which has a strong impact on their learning success. Yet, to date no study has assessed the quality of physical examination related feedback by PIs. Therefore, we conducted a randomized controlled study comparing feedback of PIs and faculty staff following a physical examination assessed by students and video assessors. Methods 14 PIs and 14 different faculty staff physicians both delivered feedback to 40 medical students that had performed a physical examination on the respective PI while the physicians observed the performance. The physical examination was rated by two independent video assessors to provide an objective performance standard (gold standard). Feedback of PI and physicians was content analyzed by two different independent video assessors based on a provided checklist and compared to the performance standard. Feedback of PIs and physicians was also rated by medical students and video assessors using a questionnaire consisting of 12 items. Results There was no statistical significant difference concerning overall matching of physician or PI feedback with gold standard ratings by video assessment (p = .219). There was also no statistical difference when focusing only on items that were classified as major key steps (p = .802), mistakes or parts that were left out during physical examination (p = .219) or mistakes in communication items (p = .517). The feedback of physicians was significantly better rated than PI feedback both by students (p = .043) as well as by video assessors (p = .034). Conclusions In summary, our study demonstrates that trained PIs are able to provide feedback of equal quantitative value to that of faculty staff physicians with regard to a physical examination performed on them. However, both the students and the video raters judged the quality of the feedback given by the physicians to be significantly better than that of the PIs.

Self-perceived coping resources of middle-aged and older adults – results of a large population-based study

ABSTRACT Objectives: Psychosocial resources (personal resources, social resources, and other) are important for coping with aging and impairment. The aim of this study was to describe the resources of older adults and to compare subgroups with frailty, complex health care needs, and/or mental disorders. Method: At the third follow-up of the large population-based German ESTHER study, 3124 elderly persons (aged 55–85) were included. Psychosocial resources were assessed during a home visit by trained study doctors by using a list of 26 different items. Resources were described for the total group, separated by sex, and for the three subgroups of persons with frailty, complex health care needs, and mental disorders. Results: Family, self-efficacy, and financial security were the most frequently reported resources of older adults. Women and men showed significant differences in their self-perceived resources. Personal resources (self-efficacy, optimism, mastery), social resources, and financial security were reported significantly less frequently by frail persons, persons with complex health care needs, and mentally ill older adults compared to non-impaired participants. Apart from external support, patients who experienced complex health care needs reported resources less frequently compared to frail and mentally ill patients. Conclusion: Coping resources in older adults are associated with sex and impairment. Evaluation and support of personal resources of frail or mentally ill persons or individuals with complex health care needs should be integrated in the therapeutic process.