No abstract

An educational intervention in CVC insertion significantly improved patient outcomes. Simulation-based education is a valuable adjunct in residency education.

Background: Racial/ethnic disparities in health care are well documented, but less is known about whether disparities occur within or between hospitals for specific inpatient processes of care. We assessed racial/ethnic disparities using the Hospital Quality Alliance Inpatient Quality of Care Indicators. Methods: We performed an observational study using patient-level data for acute myocardial infarction (5 care measures), congestive heart failure (2 measures), community-acquired pneumonia (2 measures), and patient counseling (4 measures). Data were obtained from 123 hospitals reporting to the University HealthSystem Consortium from the third quarter of 2002 to the first quarter of 2005. A total of 320 970 patients 18 years or older were eligible for at least 1 of the 13 measures. Results: There were consistent unadjusted differences between minority and nonminority patients in the quality of care across 8 of 13 quality measures (from 4.63 and 4.55 percentage points for angiotensin-converting enzyme inhibitors for acute myocardial infarction and con-gestive heart failure [PϽ.01] to 14.58 percentage points for smoking cessation counseling for pneumonia [P=.02]). Disparities were most pronounced for counseling measures. In multivariate models adjusted for individual patient characteristics and hospital effect, the magnitude of the disparities decreased substantially, yet remained significant for 3 of the 4 counseling measures; acute myocardial infarction (unadjusted, 9.00 [PϽ.001]; adjusted, 3.82 [PϽ.01]), congestive heart failure (unadjusted, 8.45 [P = .02]; adjusted, 3.54 [P = .02]), and community-acquired pneumonia (unadjusted, 14.58 [P =.02]; adjusted, 4.96 [P =.01]). Conclusions: Disparities in clinical process of care measures are largely the result of differences in where minority and nonminority patients seek care. However, disparities in services requiring counseling exist within hospitals after controlling for site of care. Policies to reduce disparities should consider the underlying reasons for the disparities.

BACKGROUND: Internal medicine residents must be competent in advanced cardiac life support (ACLS) for board certification. OBJECTIVE: To use a medical simulator to assess postgraduate year 2 (PGY‐2) residents' baseline proficiency in ACLS scenarios and evaluate the impact of an educational intervention grounded in deliberate practice on skill development to mastery standards. DESIGN: Pretest‐posttest design without control group. After baseline evaluation, residents received 4, 2‐hour ACLS education sessions using a medical simulator. Residents were then retested. Residents who did not achieve a research‐derived minimum passing score (MPS) on each ACLS problem had more deliberate practice and were retested until the MPS was reached. PARTICIPANTS: Forty‐one PGY‐2 internal medicine residents in a university‐affiliated program. MEASUREMENTS: Observational checklists based on American Heart Association (AHA) guidelines with interrater and internal consistency reliability estimates; deliberate practice time needed for residents to achieve minimum competency standards; demographics; United States Medical Licensing Examination Step 1 and Step 2 scores; and resident ratings of program quality and utility. RESULTS: Performance improved significantly after simulator training. All residents met or exceeded the mastery competency standard. The amount of practice time needed to reach the MPS was a powerful (negative) predictor of posttest performance. The education program was rated highly. CONCLUSIONS: A curriculum featuring deliberate practice dramatically increased the skills of residents in ACLS scenarios. Residents needed different amounts of training time to achieve minimum competency standards. Residents enjoy training, evaluation, and feedback in a simulated clinical environment. This mastery learning program and other competency‐based efforts illustrate outcome‐based medical education that is now prominent in accreditation reform of residency education.

A simulation-based educational intervention in CVC insertion was highly cost-effective. These results suggest that investment in simulation training can produce significant medical care cost savings.

Surgeon volume and certification are significantly related to better patient outcomes for patients who undergo CEA and AAA. In addition, surgeons with high volumes demonstrated consistently lower mortality and morbidity rates than did surgeons with low volumes. Hospital volume for a given procedure also is correlated with better outcomes.

Performance improved significantly after simulator training. No improvement was detected as a function of clinical experience alone. The educational program was rated highly.

Use of a simulation-based educational program enabled us to achieve and maintain high levels of resident performance in simulated ACLS events. Given the limitations of traditional methods to train, assess and maintain competence, simulation technology can be a useful adjunct in high-quality ACLS education.