Web-Based Immersive Virtual Patient Simulators: Positive Effect on Clinical Reasoning in Medical Education

Background

Clinical reasoning is based on the declarative and procedural knowledge of workflows in clinical medicine. Educational approaches such as problem-based learning or mannequin simulators support learning of procedural knowledge. Immersive patient simulators (IPSs) go one step further as they allow an illusionary immersion into a synthetic world. Students can freely navigate an avatar through a three-dimensional environment, interact with the virtual surroundings, and treat virtual patients. By playful learning with IPS, medical workflows can be repetitively trained and internalized. As there are only a few university-driven IPS with a profound amount of medical knowledge available, we developed a university-based IPS framework. Our simulator is free to use and combines a high degree of immersion with in-depth medical content. By adding disease-specific content modules, the simulator framework can be expanded depending on the curricular demands. However, these new educational tools compete with the traditional teaching

Objective

It was our aim to develop an educational content module that teaches clinical and therapeutic workflows in surgical oncology. Furthermore, we wanted to examine how the use of this module affects student performance.

Methods

The new module was based on the declarative and procedural learning targets of the official German medical examination regulations. The module was added to our custom-made IPS named ALICE (Artificial Learning Interface for Clinical Education). ALICE was evaluated on 62 third-year students.

Results

Students showed a high degree of motivation when using the simulator as most of them had fun using it. ALICE showed positive impact on clinical reasoning as there was a significant improvement in determining the correct therapy after using the simulator. ALICE positively impacted the rise in declarative knowledge as there was improvement in answering multiple-choice questions before and after simulator use.

Conclusions

ALICE has a positive effect on knowledge gain and raises students’ motivation. It is a suitable tool for supporting clinical education in the blended learning context.     

Clinical Geropsychology and Primary Care: Progress and Prospects

This paper comments on the review by Arean & Ayalon (this issue) and on implications for the further development of clinical geropsychology in primary care. The review provides an outstanding summary of the impressive scientific progress that has occurred in this field over the past decade. Comments focus on prospects for the future of geropsychologists in primary-care settings. Psychologists have been major contributors to research in this area but are not assured of major clinical roles in behavioral healthcare delivery. As a profession, clinical psychology must attend to developing reimbursable clinical roles for psychologists and to training psychologists who are prepared for the challenges of primary-care geropsychology.     

Exploring the Efficacy of Replacing Linear Paper-Based Patient Cases in Problem-Based Learning With Dynamic Web-Based Virtual Patients: Randomized Controlled Trial

Background

Problem-based learning (PBL) is well established in medical education and beyond, and continues to be developed and explored. Challenges include how to connect the somewhat abstract nature of classroom-based PBL with clinical practice and how to maintain learner engagement in the process of PBL over time.

Objective

A study was conducted to investigate the efficacy of decision-PBL (D-PBL), a variant form of PBL that replaces linear PBL cases with virtual patients. These Web-based interactive cases provided learners with a series of patient management pathways. Learners were encouraged to consider and discuss courses of action, take their chosen management pathway, and experience the consequences of their decisions. A Web-based application was essential to allow scenarios to respond dynamically to learners’ decisions, to deliver the scenarios to multiple PBL classrooms in the same timeframe, and to record centrally the paths taken by the PBL groups.

Methods

A randomized controlled trial in crossover design was run involving all learners (N=81) in the second year of the graduate entry stream for the undergraduate medicine program at St George’s University of London. Learners were randomized to study groups; half engaged in a D-PBL activity whereas the other half had a traditional linear PBL activity on the same subject material. Groups alternated D-PBL and linear PBL over the semester. The measure was mean cohort performance on specific face-to-face exam questions at the end of the semester.

Results

D-PBL groups performed better than linear PBL groups on questions related to D-PBL with the difference being statistically significant for all questions. Differences between the exam performances of the 2 groups were not statistically significant for the questions not related to D-PBL. The effect sizes for D-PBL–related questions were large and positive (>0.6) except for 1 question that showed a medium positive effect size. The effect sizes for questions not related to D-PBL were all small (≤0.3) with a mix of positive and negative values.

Conclusions

The efficacy of D-PBL was indicated by improved exam performance for learners who had D-PBL compared to those who had linear PBL. This suggests that the use of D-PBL leads to better midterm learning outcomes than linear PBL, at least for learners with prior experience with linear PBL. On the basis of tutor and student feedback, St George’s University of London and the University of Nicosia, Cyprus have replaced paper PBL cases for midstage undergraduate teaching with D-PBL virtual patients, and 6 more institutions in the ePBLnet partnership will be implementing D-PBL in Autumn 2015.     

Mental Health Needs of Older Adults and Primary Care: Opportunity for Interdisciplinary Geriatric Team Practice

The convergence of a number of disparate factors has led to opportunities to help address the mental health needs of older adults in primary care (PC) or "integrated care" settings. Older adults are disproportionately high users of health care resources, and cost projections for coming decades have catastrophic implications. Elders shun mental health services, instead turning to their personal physicians when troubled. The PC system is clogged with patients without medical problems or whose medical conditions are exacerbated by psychosocial factors (estimated at 60% to 70%), resulting in overutilization of services and high costs. However, PC physicians detect and adequately treat or refer only 40% to 50% of patients with mental health problems. Early experience with brief and/or structured interventions in PC settings is promising and suggests opportunities for multidisciplinary team geriatric practice.     

Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England

Background

Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.

Aim

The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.

Design and setting

Retrospective cross-sectional study in general practices in England.

Method

Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering.

Results

GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.

Conclusion

Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’.     

Health Locus of Control in a Primary Care Sample of Alcoholics and Nonalcoholics

Abstract

This study examined differences between alcoholics and nonalcoholics in a primary care population on the internal, chance, and powerful others sub-scales of the Multidimensional Health Locus of Control Scale (MHLC). Two hundred eighty subjects were divided into four groups (alcoholics with a family history of alcoholism, alcoholics with no family history of alcoholism, nonalcoholics with a family history of alcoholism, and nonalcoholics with no family history of the disease) based on DSM-III criteria for alcoholism and a family history of alcoholism. There were no differences between groups on the internal and powerful others scales. Nonalcoholics with a family history of alcoholism scored significantly lower on the chance scale than did alcoholics with a family history of the disease.     

Comparison of Virtual Patient Simulation With Mannequin-Based Simulation for Improving Clinical Performances in Assessing and Managing Clinical Deterioration: Randomized Controlled Trial

Background

Virtual patient simulation has grown substantially in health care education. A virtual patient simulation was developed as a refresher training course to reinforce nursing clinical performance in assessing and managing deteriorating patients.

Objective

The objective of this study was to describe the development of the virtual patient simulation and evaluate its efficacy, by comparing with a conventional mannequin-based simulation, for improving the nursing students’ performances in assessing and managing patients with clinical deterioration.

Methods

A randomized controlled study was conducted with 57 third-year nursing students who were recruited through email. After a baseline evaluation of all participants’ clinical performance in a simulated environment, the experimental group received a 2-hour fully automated virtual patient simulation while the control group received 2-hour facilitator-led mannequin-based simulation training. All participants were then re-tested one day (first posttest) and 2.5 months (second posttest) after the intervention. The participants from the experimental group completed a survey to evaluate their learning experiences with the newly developed virtual patient simulation.

Results

Compared to their baseline scores, both experimental and control groups demonstrated significant improvements (P<.001) in first and second post-test scores. While the experimental group had significantly lower (P<.05) second post-test scores compared with the first post-test scores, no significant difference (P=.94) was found between these two scores for the control group. The scores between groups did not differ significantly over time (P=.17). The virtual patient simulation was rated positively.

Conclusions

A virtual patient simulation for a refreshing training course on assessing and managing clinical deterioration was developed. Although the randomized controlled study did not show that the virtual patient simulation was superior to mannequin-based simulation, both simulations have demonstrated to be effective refresher learning strategies for improving nursing students’ clinical performance. Given the greater resource requirements of mannequin-based simulation, the virtual patient simulation provides a more promising alternative learning strategy to mitigate the decay of clinical performance over time.     

The Clinical Effectiveness of Web-Based Cognitive Behavioral Therapy With Face-to-Face Therapist Support for Depressed Primary Care Patients: Randomized Controlled Trial

Background

Most patients with mild to moderate depression receive treatment in primary care, but despite guideline recommendations, structured psychological interventions are infrequently delivered. Research supports the effectiveness of Internet-based treatment for depression; however, few trials have studied the effect of the MoodGYM program plus therapist support. The use of such interventions could improve the delivery of treatment in primary care.

Objective

To evaluate the effectiveness and acceptability of a guided Web-based intervention for mild to moderate depression, which could be suitable for implementation in general practice.

Methods

Participants (N=106) aged between 18 and 65 years were recruited from primary care and randomly allocated to a treatment condition comprising 6 weeks of therapist-assisted Web-based cognitive behavioral therapy (CBT), or to a 6-week delayed treatment condition. The intervention included the Norwegian version of the MoodGYM program, brief face-to-face support from a psychologist, and reminder emails. The primary outcome measure, depression symptoms, was measured by the Beck Depression Inventory-II (BDI-II). Secondary outcome measures included the Beck Anxiety Inventory (BAI), the Hospital Anxiety and Depression Scale (HADS), the Satisfaction with Life Scale (SWLS), and the EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D). All outcomes were based on self-report and were assessed at baseline, postintervention, and at 6-month follow-up.

Results

Postintervention measures were completed by 37 (71%) and 47 (87%) of the 52 participants in the intervention and 54 participants in the delayed treatment group, respectively. Linear mixed-models analyses revealed a significant difference in time trends between the groups for the BDI-II, (P=.002), for HADS depression and anxiety subscales (P<.001 and P=.001, respectively), and for the SWLS (P<.001). No differential group effects were found for the BAI and the EQ-5D. In comparison to the control group, significantly more participants in the intervention group experienced recovery from depression as measured by the BDI-II. Of the 52 participants in the treatment program, 31 (60%) adhered to the program, and overall treatment satisfaction was high. The reduction of depression and anxiety symptoms was largely maintained at 6-month follow-up, and positive gains in life satisfaction were partly maintained.

Conclusions

The intervention combining MoodGYM and brief therapist support can be an effective treatment of depression in a sample of primary care patients. The intervention alleviates depressive symptoms and has a significant positive effect on anxiety symptoms and satisfaction with life. Moderate rates of nonadherence and predominately positive evaluations of the treatment also indicate the acceptability of the intervention. The intervention could potentially be used in a stepped-care approach, but remains to be tested in regular primary health care.

Trial Registration

Australian New Zealand Clinical Trials Registry: ACTRN12610000257066; http://apps.who.int/trialsearch/trial.aspx?trialid=ACTRN12610000257066 (Archived by WebCite at http://www.webcitation.org/6Ie3YhIZa).     

Clinical anatomy as the basis for clinical examination: development and evaluation of an Introduction to Clinical Examination in a problem-oriented medical curriculum

Clinical anatomy is usually defined as anatomy applied to patient care. The question is asked whether students of a new horizontally and vertically integrated medical curriculum recognize the subject as the basis for clinical examination. A clinical anatomy practicum was developed in the special activity, "Introduction to Clinical Medicine," held in the second year of the Pretoria medical curriculum. The practicum was conducted on a station basis to anatomically prepare the student for the inspection, palpation, percussion, and auscultation of the cardiovascular, respiratory, abdominal, and urogenital systems. A total of 23 stations consisting of eight cardiovascular, seven respiratory, and eight abdominal/urogenital stations were designed. Standardized patients, cadavers, skeletons, prosected specimens, x-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), multimedia programs, and clinical case studies were used as resources. A Likert-type questionnaire was used for student evaluation of the practicum. Most students realized the importance of surface anatomy for a family physician. More than two-thirds thought the practicum improved their understanding of the anatomical basis for clinical examination. The minority of students were stimulated to do further reading on clinical examination. The students' response to their ability to integrate the clinical examination with the radiological anatomy was average. Most students were continuously aware of the appropriateness of the practicum for their future career. We conclude that medical students recognize the importance of anatomy as the basis for clinical examination when exposed to an appropriate integrated presentation format.     

Implementing a Virtual Community of Practice for Family Physician Training: A Mixed-Methods Case Study

Background

GP training in Australia can be professionally isolating, with trainees spread across large geographic areas, leading to problems with rural workforce retention. Virtual communities of practice (VCoPs) may provide a way of improving knowledge sharing and thus reducing professional isolation.

Objective

The goal of our study was to review the usefulness of a 7-step framework for implementing a VCoP for general practitioner (GP) training and then evaluated the usefulness of the resulting VCoP in facilitating knowledge sharing and reducing professional isolation.

Methods

The case was set in an Australian general practice training region involving 55 first-term trainees (GPT1s), from January to July 2012. ConnectGPR was a secure, online community site that included standard community options such as discussion forums, blogs, newsletter broadcasts, webchats, and photo sharing. A mixed-methods case study methodology was used. Results are presented and interpreted for each step of the VCoP 7-step framework and then in terms of the outcomes of knowledge sharing and overcoming isolation.

Results

Step 1, Facilitation: Regular, personal facilitation by a group of GP trainers with a co-ordinating facilitator was an important factor in the success of ConnectGPR. Step 2, Champion and Support: Leadership and stakeholder engagement were vital. Further benefits are possible if the site is recognized as contributing to training time. Step 3, Clear Goals: Clear goals of facilitating knowledge sharing and improving connectedness helped to keep the site discussions focused. Step 4, A Broad Church: The ConnectGPR community was too narrow, focusing only on first-term trainees (GPT1s). Ideally there should be more involvement of senior trainees, trainers, and specialists. Step 5, A Supportive Environment: Facilitators maintained community standards and encouraged participation. Step 6, Measurement Benchmarking and Feedback: Site activity was primarily driven by centrally generated newsletter feedback. Viewing comments by other participants helped users benchmark their own knowledge, particularly around applying guidelines. Step 7, Technology and Community: All the community tools were useful, but chat was limited and users suggested webinars in future. A larger user base and more training may also be helpful. Time is a common barrier. Trust can be built online, which may have benefit for trainees that cannot attend face-to-face workshops. Knowledge sharing and isolation outcomes: 28/34 (82%) of the eligible GPT1s enrolled on ConnectGPR. Trainees shared knowledge through online chat, forums, and shared photos. In terms of knowledge needs, GPT1s rated their need for cardiovascular knowledge more highly than supervisors. Isolation was a common theme among interview respondents, and ConnectGPR users felt more supported in their general practice (13/14, 92.9%).

Conclusions

The 7-step framework for implementation of an online community was useful. Overcoming isolation and improving connectedness through an online knowledge sharing community shows promise in GP training. Time and technology are barriers that may be overcome by training, technology, and valuable content. In a VCoP, trust can be built online. This has implications for course delivery, particularly in regional areas. VCoPs may also have a specific role assisting overseas trained doctors to interpret their medical knowledge in a new context.     

The benefits and costs of a master's programme in primary health care: a cross-sectional postal survey

Background

Master''s programmes can provide continuing professional development, equipping GPs to teach, research, and lead general practice. A previous evaluation of the MSc in primary health care found that graduates were contributing significantly to the discipline of general practice. Given the changes in general practice over the last 10 years, it was considered useful to investigate longer-term outcomes.

Aim

To assess the benefits GPs have derived from the MSc in terms of the intended learning outcomes and their own plans for involvement in research and teaching.

Design of study

A cross-sectional survey using a postal questionnaire.

Setting

Department of Primary Care and Public Health Sciences, King''s College London.

Method

A postal questionnaire was sent to the graduates of MSc in primary health care from 1997 until 2008.

Results

A total of 50 completed questionnaires were returned (response rate 76%). After graduation, 22 GPs had completed another degree or diploma and 21 had work accepted for publication, resulting in 74 papers. Nine held academic posts at lecturer or senior lecturer level, 21 were GP trainers, and 21 undergraduate teachers. Twenty-five GPs held more than one teaching-related post. The majority of the graduates confirmed the attainment of the MSc''s intended outcomes. Positive influences of the MSc were identified, including career development, personal development, and job satisfaction.

Conclusion

Graduates reported a number of benefits to themselves, their practices, and their patients. As the requirements for continuing professional development of GPs become more stringent, and with the advent of revalidation, the current ad hoc approach to career development in general practice is becoming unsustainable. To enhance its credibility as an academic discipline, general practice must continue to develop its capacity for research and scholarship. Master''s programmes are likely to have an important role in supporting professional development in general practice in the future.     

A Virtual Emergency Telemedicine Serious Game in Medical Training: A Quantitative,Professional Feedback-Informed Evaluation Study

Background

Serious games involving virtual patients in medical education can provide a controlled setting within which players can learn in an engaging way, while avoiding the risks associated with real patients. Moreover, serious games align with medical students’ preferred learning styles. The Virtual Emergency TeleMedicine (VETM) game is a simulation-based game that was developed in collaboration with the mEducator Best Practice network in response to calls to integrate serious games in medical education and training. The VETM game makes use of data from an electrocardiogram to train practicing doctors, nurses, or medical students for problem-solving in real-life clinical scenarios through a telemedicine system and virtual patients. The study responds to two gaps: the limited number of games in emergency cardiology and the lack of evaluations by professionals.

Objective

The objective of this study is a quantitative, professional feedback-informed evaluation of one scenario of VETM, involving cardiovascular complications. The study has the following research question: “What are professionals’ perceptions of the potential of the Virtual Emergency Telemedicine game for training people involved in the assessment and management of emergency cases?”

Methods

The evaluation of the VETM game was conducted with 90 professional ambulance crew nursing personnel specializing in the assessment and management of emergency cases. After collaboratively trying out one VETM scenario, participants individually completed an evaluation of the game (36 questions on a 5-point Likert scale) and provided written and verbal comments. The instrument assessed six dimensions of the game: (1) user interface, (2) difficulty level, (3) feedback, (4) educational value, (5) user engagement, and (6) terminology. Data sources of the study were 90 questionnaires, including written comments from 51 participants, 24 interviews with 55 participants, and 379 log files of their interaction with the game.

Results

Overall, the results were positive in all dimensions of the game that were assessed as means ranged from 3.2 to 3.99 out of 5, with user engagement receiving the highest score (mean 3.99, SD 0.87). Users’ perceived difficulty level received the lowest score (mean 3.20, SD 0.65), a finding which agrees with the analysis of log files that showed a rather low success rate (20.6%). Even though professionals saw the educational value and usefulness of the tool for pre-hospital emergency training (mean 3.83, SD 1.05), they identified confusing features and provided input for improving them.

Conclusions

Overall, the results of the professional feedback-informed evaluation of the game provide a strong indication of its potential as an educational tool for emergency training. Professionals’ input will serve to improve the game. Further research will aim to validate VETM, in a randomized pre-test, post-test control group study to examine possible learning gains in participants’ problem-solving skills in treating a patient’s symptoms in an emergency situation.     

Development of a tool to assess the impact of a brief counseling curriculum: Validation of the Attitudes to Psychological Interventions and Counseling in Primary Care (APIC-PC) survey

Objective

To develop and validate an instrument to assess knowledge and attitudes regarding the use of psychological interventions in primary care.

Methods

A 13-item questionnaire was developed based on literature review and expert panel discussion. Exploratory and confirmatory factor analyses were carried out to test the construct validity of the subscales. Item-scale correlations were used to test the construct validity of the items. Internal reliability was tested by Cronbach's alpha. Responsiveness of the instrument was evaluated by using independent t-test of pre and post program scores.

Results

Exploratory factor analysis extracted four factors: skills and knowledge, confidence to provide counseling, willingness to provide counseling, and curriculum needs. Confirmatory factor analysis demonstrated excellent goodness-of-fit. Item scale correlations confirmed convergent and discriminant validity. Good responsiveness was shown on independent t-test of the pre and post responses.

Conclusions

The Attitudes to Psychological Interventions and Counseling in Primary Care (APIC-PC) survey is a valid and responsive instrument for assessing knowledge and attitudes regarding psychological approaches in patient management (mental health care).

Practice implications

Psycho-social counseling skills training is increasingly being recognised as a valuable component of undergraduate primary care medical education. The APIC-PC is a useful tool for evaluating the impact of such programs.     

Perceptions of Family Physician Trainees and Trainers Regarding the Usefulness of a Virtual Community of Practice

BackgroundTraining for Australian general practice, or family medicine, can be isolating, with registrars (residents or trainees) moving between rural and urban environments, and between hospital and community clinic posts. Virtual communities of practice (VCoPs), groups of people sharing knowledge about their domain of practice online and face-to-face, may have a role in overcoming the isolation associated with general practice training.ObjectiveThis study explored whether Australian general practice registrars and their supervisors (trainers) would be able to use, and would be interested in using, a VCoP in the form of a private online network for work and training purposes. It also sought to understand the facilitators and barriers to intention to use such a community, and considers whether any of these factors may be modifiable.MethodsA survey was developed assessing computer, Internet, and social media access and usage, confidence, perceived usefulness, and barriers, facilitators, and intentions to use a private online network for training purposes. The survey was sent by email link to all 139 registrars and 224 supervisors in one of Australia’s 17 general practice training regions. Complete and usable responses were received from 131 participants (response rate=0.4).ResultsMost respondents had access to broadband at home (125/131, 95.4%) and at work (130/131, 99.2%). Registrars were more likely to spend more than 2 hours on the Internet (P=.03), and to use social media sites for nonwork purposes (P=.01). On a 5-point Likert scale, confidence was high (mean 3.93, SD 0.63) and was negatively associated with higher age (P=.04), but not associated with training stage. Social media confidence was lower, with registrars more confident than supervisors for almost all social media activities. On a 5-point Likert scale, overall usefulness was scored positively (n=123, mean 3.63, SD 0.74), and was not significantly associated with age or training level. The main concerns of respondents were worries about privacy (registrar: 61/81, 75.3%; supervisor: 30/50, 60.0%) and insufficient time (registrar: 41/81, 50.6%; supervisor: 36/50, 72.0%). Using a multivariate generalized linear regression model, training stage and perceived usefulness were positively predictive, and concerns about privacy and time were negatively predictive of intention to use a private online network.ConclusionsGeneral practice registrars and supervisors are interested in using a private online network, or VCoP, for work and training purposes. Important considerations are the extent to which concerns such as privacy and usefulness may be overcome by training and support to offset some other concerns, such as time barriers. Participants at an early stage in their training are more receptive to using an online network. More senior registrars and supervisors may benefit from more training and promotion of the online network to improve their receptiveness.     

A Web-Based Program Improves Physical Activity Outcomes in a Primary Care Angina Population: Randomized Controlled Trial

Background

Angina affects more than 50 million people worldwide. Secondary prevention interventions such as cardiac rehabilitation are not widely available for this population. An Internet-based version could offer a feasible alternative.

Objective

Our aim was to examine the effectiveness of a Web-based cardiac rehabilitation program for those with angina.

Methods

We conducted a randomized controlled trial, recruiting those diagnosed with angina from general practitioners (GPs) in primary care to an intervention or control group. Intervention group participants were offered a 6-week Web-based rehabilitation program (“ActivateYourHeart”). The program was introduced during a face-to-face appointment and then delivered via the Internet (no further face-to-face contact). The program contained information about the secondary prevention of coronary heart disease (CHD) and set each user goals around physical activity, diet, managing emotions, and smoking. Performance against goals was reviewed throughout the program and goals were then reset/modified. Participants completed an online exercise diary and communicated with rehabilitation specialists through an email link/synchronized chat room. Participants in the control group continued with GP treatment as usual, which consisted of being placed on a CHD register and attending an annual review. Outcomes were measured at 6-week and 6-month follow-ups during face-to-face assessments. The primary outcome measure was change in daily steps at 6 weeks, measured using an accelerometer. Secondary outcome measures were energy expenditure (EE), duration of sedentary activity (DSA), duration of moderate activity (DMA), weight, diastolic/systolic blood pressure, and body fat percentage. Self-assessed questionnaire outcomes included fat/fiber intake, anxiety/depression, self-efficacy, and quality of life (QOL).

Results

A total of 94 participants were recruited and randomized to the intervention (n=48) or the usual care (n=46) group; 84 and 73 participants completed the 6-week and 6-month follow-ups, respectively. The mean number of log-ins to the program was 18.68 (SD 13.13, range 1-51), an average of 3 log-ins per week per participant. Change in daily steps walked at the 6-week follow-up was +497 (SD 2171) in the intervention group and –861 (SD 2534) in the control group (95% CI 263-2451, P=.02). Significant intervention effects were observed at the 6-week follow-up in EE (+43.94 kcal, 95% CI 43.93-309.98, P=.01), DSA (–7.79 minutes, 95% CI –55.01 to –7.01, P=.01), DMA (+6.31 minutes, 95% CI 6.01-51.20, P=.01), weight (–0.56 kg, 95% CI –1.78 to –0.15, P=.02), self-efficacy (95% CI 0.30-4.79, P=.03), emotional QOL score (95% CI 0.01-0.54, P=.04), and angina frequency (95% CI 8.57-35.05, P=.002). Significant benefits in angina frequency (95% CI 1.89-29.41, P=.02) and social QOL score (95% CI 0.05-0.54, P=.02) were also observed at the 6-month follow-up.

Conclusions

An Internet-based secondary prevention intervention could be offered to those with angina. A larger pragmatic trial is required to provide definitive evidence of effectiveness and cost-effectiveness.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 90110503; http://www.controlled-trials.com/ISRCTN90110503/ISRCTN90110503 (Archived by WebCite at http://www.webcitation.org/6RYVOQFKM).     

Maximising recruitment and retention of general practices in clinical trials: a case study

Background

There is limited evidence regarding the factors that facilitate recruitment and retention of general practices in clinical trials. It is therefore pertinent to consider the factors that facilitate research in primary care.

Aim

To formulate hypotheses about effective ways of recruiting and retaining practices to clinical trials, based on a case study.

Design of study

Case study of practice recruitment and retention to a trial of delivering antenatal sickle cell and thalassaemia screening.

Setting

Two UK primary care trusts with 123 practices, with a high incidence of sickle cell and thalassaemia, and high levels of social deprivation.

Method

Practices were invited to take part in the trial using a research information sheet for practices. Invitations were sent to all practice managers, GPs, practice nurses, and nurse practitioners. Expenses of approximately £3000 per practice were available. Practices and the research team signed research activity agreements, detailing a payment schedule based on deliverables. Semi-structured interviews were completed with 20 GPs who participated in the trial. Outcome measures were the number of practices recruited to, and completing, the trial.

Results

Four practices did not agree to randomisation and were excluded. Of 119 eligible practices, 29 expressed an interest in participation. Two practices withdrew from the trial and 27 participated (two hosted pilot studies and 25 completed the trial), giving a retention rate of 93% (27/29). The 27 participating practices did not differ from non-participating practices in list size, number of GPs, social deprivation, or minority ethnic group composition of the practice population.

Conclusion

Three factors appeared important in recruiting practices: research topic, invitation method, and interest in research. Three factors appeared important in retaining practices: good communication, easy data-collection methods, and payment upon meeting pre-agreed targets. The effectiveness of these factors at facilitating recruitment and retention requires assessment in experimental studies.     

应用虚拟盒块测试系统评估脑卒中患者上肢运动功能的可行性研究

目的 评估力反馈设备结合虚拟现实技术设计的虚拟盒块测试(virtual box and block test, VBBT)用于远程评估上肢运动功能的可行性。方法 设计了一个VBBT系统用于评估上肢运动功能。该系统可用于计算受试者的VBBT得分、平均速度、运动谱弧长、耗能和平均抓握力。共招募20名健康受试者和16名脑卒中患者进行VBBT。结果 脑卒中患者与健康受试者在VBBT参数的对比上均具有显著性差异(P<0.05);接收者工作特征(receiver operating characteristic, ROC)曲线表明,VBBT参数可区分脑卒中患者和健康受试者的表现(P<0.05)。脑卒中患者VBBT参数与传统临床评估的相关性分析结果表明,VBBT参数的共时效度;多元回归分析结果显示,VBBT的运动学和力学参数能够补充性解释传统临床评估。结论 VBBT可用于远程评估脑卒中患者的上肢运动功能。     

Recognising Kawasaki disease in UK primary care: a descriptive study using the Clinical Practice Research Datalink

Background

Kawasaki disease is a rare childhood illness that can present non-specifically, making it a diagnostic challenge. The clinical presentation of Kawasaki disease has not been previously described in primary care.

Aim

To describe how children with an eventual diagnosis of Kawasaki disease initially present to primary care in the UK.

Design and setting

The Clinical Practice Research Datalink was used to find cases coded as Kawasaki disease. Hospital Episode Statistics, hospital admissions, and hospital outpatient attendances were used to identify the children with a convincing diagnosis of Kawasaki disease.

Method

Questionnaires and a request for copies of relevant hospital summaries, discharge letters, and reports were sent to GPs of the 104 children with a diagnosis of Kawasaki disease between 2007 and 2011.

Results

Most children presented with few clinical features typical of Kawasaki disease. Of those with just one feature, a fever or a polymorphous rash were the most common. By the time that most children were admitted to hospital they had a more recognisable syndrome, with three or more clinical features diagnostic of Kawasaki disease. Most GPs did not consider Kawasaki disease among their differential diagnoses, but some GPs did suspect that the child’s illness was unusual.

Conclusion

The study highlighted the difficulty of early diagnosis, with most children having a non-specific presentation to primary care. GPs are encouraged to implement good safety netting, and to keep Kawasaki disease in mind when children present with fever and rashes.