International Family-planning Training for Nurse Practitioners

Since the mid-1970s, the Margaret Sanger Center of Planned Parenthood of New York City has prepared nurses and nurse midwives from less developed countries to be family-planning nurse practitioners. These nurse practitioners then provide services to patients, train other staff, and manage integrated family-planning clinics. More than 120 nurses and nurse midwives have arrived in groups of 10 at the Sanger Center, with 72 attending since 1981. Each course lasts 10 weeks. The core curriculum provides trainees with skills in women's health care including contraception, in training and advocacy, and in management of clinics. Whether, in the current period of scarce resources, cross-cultural training programs of this type remain a worthwhile investment, and if so, which of their components are most important to this success, is assessed.     

Rural Hospital Inpatient Surgical Volume: Cutting-edge Service or Operating on the Margin?

Surgical services are an important part of modern health care, but providing them to isolated rural citizens is especially difficult. Public policy initiatives could influence the supply, training, and distribution of surgeons, much as they have for rural primary care providers. However, so little is known about the proper distribution of surgeons, their contribution to rural health care, and the safety of rural surgery that policy cannot be shaped with confidence. This study examined the volume and complexity of inpatient surgery in rural Washington state as a first step toward a better understanding of the current status of rural surgical services. Information about rural surgical providers was obtained through telephone interviews with administrators at Washington's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data provided a count of the annual surgical admissions at rural hospitals. Diagnosis-related group (DRG) weights were used to measure complexity of rural surgical cases. Surgical volume varied greatly among hospitals, even among those with a similar mix of surgical providers. Many hospitals provided a limited set of basic surgical services, while some performed more complex procedures. None of these rural hospitals could be considered high volume when compared to volumes at Seattle hospitals or to research reference criteria that have assessed volume-outcome relationships for surgical procedures. Several hospitals had very low volumes for some complex procedures, raising a question about the safety of performing them. The leaders of small rural hospitals must recognize not only the fiscal and service benefits of surgical services--and these are considerable--but also the potentially adverse effect of low surgical volume on patient outcomes. Policies that encourage the proper training and distribution of surgeons, the retention of basic rural surgical services, and the rational regionalization of complex surgery are likely to enhance the convenience and safety of surgery for rural citizens.     

Developing a Peer Review Process for Web-based Curricula

The World Wide Web creates new challenges and opportunities for medical educators. Prominent among these are the lack of consistent standards by which to evaluate web-based educational tools. We present the instrument that was used to review web-based innovations in medical education submissions to the 2003 Society of General Internal Medicine (SGIM) national meeting, and discuss the process used by the SGIM web-based clinical curriculum interest group to develop the instrument. The 5 highest-ranked submissions are summarized with commentary from the reviewers.     

Differentiating Large-scale Surge versus Daily Surge

This breakout session at the Academic Emergency Medicine 2006 Consensus Conference examined how baseline overcrowding impedes the ability of emergency departments to respond to sudden, unexpected surges in demand for patient care. Differences between daily and catastrophic surge were discussed, and the need to invoke a hospital-wide response to surge was explored.     

Keratoacanthoma-Like Squamous Cell Carcinoma Within the Fibroepithelial Polyp

Acrochordons (skin tags) are often considered clinically insignificant cutaneous redundancies that should be removed and destroyed with no histopathologic analysis performed. One rarely finds another neoplasm within an acrochordon. We describe a patient with an acrochordon that contained a squamous cell carcinoma that had features resembling a keratoacanthoma. This is the first time to our knowledge that an invasive squamous cell carcinoma has been described within an acrochordon.     

Validation of Probabilistic Linkage to Match De-identified Ambulance Records to a State Trauma Registry

Objectives: To validate the accuracy of using probabilistic linkage for matching de‐identified ambulance records to a state trauma registry. Methods: This was a retrospective cohort analysis. Three thousand nine hundred nineteen true matches between ambulance and state trauma registry data from 1998 to 2003 were identified by deterministic matching on trauma identification number and verified by human review. Two thousand thirty‐eight ambulance records from trauma patients not meeting criteria for a true match, and an identical number of trauma registry records randomly selected from the one local county served by a different EMS provider, were included as nonmatches. There were 17 variables considered for linkage, which included the following: age, gender, race, county, hospital, date, rural setting, call and arrival times, mechanism, penetrating injury, vital signs, intubation, and intoxication. Probabilistic linkage was used to link the two data sets, using seven different combinations of common variables (maximum, 17; minimum, 4). The sensitivity and specificity of identifying true matches and nonmatches (95% confidence intervals [95% CI]) were calculated for each combination of variables. Results: Using all 17 available variables, 3,766 of 3,919 true matches were appropriately linked (sensitivity, 96.1%; 95% CI = 95.4% to 96.7%), with eight mismatches (specificity, 99.6%; 95% CI = 99.2% to 99.8%). Sensitivity fell below 95% with < 15 variables; however, sensitivity was very dependent on the inclusion of variables with high discriminatory power. Specificity remained >98% regardless of the number of variables included. Conclusions: Probabilistic linkage is a valid method for matching ambulance records to a trauma registry without the use of patient identifiers; however, the sensitivity of identifying true matches is critically dependent on the number and type of common variables included in the analysis.