What Do the Theories of Egon Brunswik Have to Say to Medical Education?

Every day physicians make judgments about patient management and diagnosis based on less than perfect information from many different sources. Judgment and decision-making research has taught us a great deal about such decisions, but these insights rarely find their way into the medical curriculum. One productive line of investigation in the study of judgment and decision making has followed the insights and theories developed by the psychologist, Egon Brunswik. His theories are becoming increasingly relevant to modern judgment problems. In this paper, I outline Brunswik’s theories, trace their development over the last 50 years and speculate on what role they should play in medical education.     

What Factors Influence States’ Capacity to Report Children’s Health Care Quality Measures? A Multiple-Case Study

Objectives The objective of this study was to describe factors that influence the ability of state Medicaid agencies to report the Centers for Medicare & Medicaid Services’ (CMS) core set of children’s health care quality measures (Child Core Set). Methods We conducted a multiple-case study of four high-performing states participating in the Children’s Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program: Illinois, Maine, Pennsylvania, and Oregon. Cases were purposively selected for their diverse measurement approaches and used data from 2010 to 2015, including 154 interviews, semiannual grant progress reports, and annual public reports on Child Core Set measures. We followed Yin’s multiple-case study methodology to describe how and why each state increased the number of measures reported to CMS. Results All four states increased the number of Child Core Set measures reported to CMS during the grant period. Each took a different approach to reporting, depending on the available technical, organizational, and behavioral inputs in the state. Reporting capacity was influenced by a state’s Medicaid data availability, ability to link to other state data systems, past experience with quality measurement, staff time and technical expertise, and demand for the measures. These factors were enhanced by CHIPRA Quality Demonstration grant funding and other federal capacity building activities, as hypothesized in our conceptual framework. These and other states have made progress reporting the Child Core Set since 2010. Conclusion With financial support and investment in state data systems and organizational factors, states can overcome challenges to reporting most of the Child Core Set measures.     

Books and Toddlers in Child Care: Under What Conditions are Children Most Engaged?

Background

Although shared book reading is seen as an effective way to support children’s early literacy and language development, less is known about the factors associated with toddlers’ engagement with books.

Objective

The goal of the current study was to examine younger and older toddlers’ engagement with books during one-on-one reading with a teacher in an interactive versus non-interactive manner and during independent exploration.

Method

Using single-case design, the study examined how engagement among toddlers (N = 6) in a childcare classroom varied under different book reading/exploration conditions.

Results

Results indicated that overall engagement was greater when teachers read interactively compared to when children explored books on their own, with this effect differing for younger versus older toddlers.

Conclusions

Understanding how teachers reading to younger and older toddlers is associated with children’s engagement with books compared to children’s engagement when exploring books on their own can inform early care and education reading practices with toddlers. Implications for book reading with toddlers in group childcare are discussed.

     

Sugars and Health Controversies: What Does the Science Say?

The consumption of sugar and its relation to various potential adverse health consequences are the subjects of considerable debate and controversy. This supplement to Advances in Nutrition provides an expanded summary of a symposium held on 26 April 2014 entitled “Sugars and Health Controversies: What Does the Science Say?” as part of the ASN Scientific Sessions and Annual Meeting at Experimental Biology 2014. The articles in the supplement discuss results of current systematic reviews and meta-analyses as well as randomized controlled trials and draw implications for public policy considerations. In addition, future research gaps are identified. Current research trials conducted with commonly consumed sugars [e.g., sucrose and high-fructose corn syrup (HFCS)] do not support a unique relation to obesity, metabolic syndrome, diabetes, risk factors for heart disease, or nonalcoholic fatty liver disease. Neurologic differences in response to studies that used pure fructose compared with pure glucose have not been confirmed using typical sugars that are consumed (i.e., sucrose and HFCS), which contain ∼50% glucose and fructose. We conclude that added sugars consumed in the normal forms in which humans consume them, at amounts typical of the human diet and for the time period studied in randomized controlled trials, do not result in adverse health consequences. Although more research trials are needed in many areas of sugar consumption and health, there is little scientific justification for recommending restricting sugar consumption below the reasonable upper limit recommended by the Dietary Guidelines for Americans, 2010 of no more than 25% of calories.     

Environmental Influences and What Have We Learned From Dietary Behavior Change With Children?

Sparse research exists on factors influencing use of dietary supplements or on programs to increase dietary supplement use among children. Borrowing from the literature concerning influences on children's diet, parents likely influence children's dietary supplement intake by controlling their availability and accessibility at home and through parenting and socialization strategies. Borrowing from the literature on programs to change diet, programs to promote dietary supplements will likely work when implemented with highly motivated individuals, delivered by specialists and promoting increased, rather than decreased, consumption. Research into these areas is warranted.     

Children with special needs--1: What choices do parents have?

In the first of two articles, a health visitor for special needs children discusses the limitations of choices open to parents of a child with disabilities. Both the child and the family often suffer restricted opportunities and rigid attitudes from health and education authorities. Provision of care is often a lottery. The author outlines new policies for improving choice, taking parents' wishes into account and providing more co-ordinated services.     

Measuring inequalities in health: What do we know? What do we need to know?

We argue that policy analysis aiming at curving inequalities in health calls for a better understanding of what we know about its measurement pathways. Assuming that health is a good that individuals trade off against other goods, unavoidable health inequalities result when after controlling for unavoidable factors (e.g., age and gender), differences in socioeconomic status of an individual systemically engender differences in health outcomes. However, the measurement of such inequality and underpinning reasons behind are not suggestive of a clear picture. In reviewing the literature, we conclude that it is unclear what the evidence suggests about the reasons for health inequalities as well as the best possible instruments to measure both inequality and socioeconomic health gradients. We provide an evaluation of the different sources of health inequity and we draw upon measurement issues and their policy significance.     

Physician-Patient Relationships: What Do Doctors Say?

A literature search of the medical literature dealing with physician-patient relationships is reported. Articles published between 1983 and 1989 were examined to discover problems in relationships as defied by physicians and motivations for physicians to improve relationships with patients. Articles related to relationships with patients constitute less than 1% of the medical literature. A content analysis of the articles revealed a number of topics that provide a fertile field of research for communication scholars who are interested in working with physicians and medical students to improve their communication skills. The articles also revealed a variety of reasons why physicians should attend to relationships with patients.     

From Adversary to Partner: Have Quality Improvement Organizations Made the Transition?

OBJECTIVE: To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement. DATA SOURCE: Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002. STUDY DESIGN: We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness. PRINCIPLE FINDINGS: More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators. CONCLUSIONS: Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians.     

What are trusts allowed to do?

NHS trusts may not be a feature of the health services for ever, but current legislation will be applicable for some time to come. Legal aspects of trust status are described in two features. In the first, Anita Morrish identifies what trusts are legally empowered to do and those areas where their powers, if they exist, are less clearly defined.     

Quality of anticoagulation control: do race and language matter?

No studies have evaluated the quality of anticoagulation control among populations characterized by low socioeconomic status, diverse racial and ethnic backgrounds, or limited English proficiency. We conducted a retrospective cohort study to evaluate the effects of race/ethnicity and language on anticoagulation outcomes among patients (N=864) receiving continuous anticoagulation services at a university-affiliated public hospital. White/non-Hispanic patients made up 24%, Asian/Pacific Islanders 33%, Hispanics 22%, African Americans 18%. English (63%), Spanish, (14%), and Cantonese (13%) were the most common languages. Mean time in therapeutic range (TTR) was 43%. After adjustment, TTR was lower for African Americans than for Whites (absolute difference, -8.7%, p< .001) and for Spanish-speaking than for English-speaking Hispanics (absolute difference, -7.2%, p< .05). There were no differences between Asian/Pacific Islanders and Whites, nor between Cantonese-speaking and English-speaking Asian/Pacific Islanders. Future research should examine mechanisms by which race/ethnicity and language affect quality of anticoagulation and evaluate programs to improve treatment in diverse communities.     

What can industry do to facilitate dietary and behavioural changes?

The food industry has five important roles in facilitating needed dietary and behavioural changes. Two of these roles are direct ones. Industry can increase the availability of a wide variety of basic commodities and new foods that help consumers meet dietary recommendations. It is also responsible for developing and formulating appealing, healthy and effective food products that decrease risks of chronic degenerative disease. Industry also plays an indirect role in facilitating dietary change by motivating consumers to select and prepare foods that will result in healthy dietary patterns. It can also participate in coalitions to facilitate other behaviours that decrease risks. Finally, it can collaborate actively in applied and fundamental research to further our understanding of the associations between food and health.     

Coaching to Quality: Increasing Quality in Early Care and Education Programmes through Community–University Partnership

This paper describes efforts to increase the quality in early care and education through targeted coaching. A collaborative including several community agencies and a university developed a framework of support for early care and education providers, using coaching as its foundational basis, called Coaching to Quality (CTQ). This paper provides a background on the regional need for increasing quality level of childcare centres, specific components and evolution of CTQ, and lessons learned or implications of the CTQ initiative.