Electronic medical record systems, data quality and loss to follow-up: survey of antiretroviral therapy programmes in resource-limited settings

OBJECTIVE: To describe the electronic medical databases used in antiretroviral therapy (ART) programmes in lower-income countries and assess the measures such programmes employ to maintain and improve data quality and reduce the loss of patients to follow-up. METHODS: In 15 countries of Africa, South America and Asia, a survey was conducted from December 2006 to February 2007 on the use of electronic medical record systems in ART programmes. Patients enrolled in the sites at the time of the survey but not seen during the previous 12 months were considered lost to follow-up. The quality of the data was assessed by computing the percentage of missing key variables (age, sex, clinical stage of HIV infection, CD4+ lymphocyte count and year of ART initiation). Associations between site characteristics (such as number of staff members dedicated to data management), measures to reduce loss to follow-up (such as the presence of staff dedicated to tracing patients) and data quality and loss to follow-up were analysed using multivariate logit models. FINDINGS: Twenty-one sites that together provided ART to 50 060 patients were included (median number of patients per site: 1000; interquartile range, IQR: 72-19 320). Eighteen sites (86%) used an electronic database for medical record-keeping; 15 (83%) such sites relied on software intended for personal or small business use. The median percentage of missing data for key variables per site was 10.9% (IQR: 2.0-18.9%) and declined with training in data management (odds ratio, OR: 0.58; 95% confidence interval, CI: 0.37-0.90) and weekly hours spent by a clerk on the database per 100 patients on ART (OR: 0.95; 95% CI: 0.90-0.99). About 10 weekly hours per 100 patients on ART were required to reduce missing data for key variables to below 10%. The median percentage of patients lost to follow-up 1 year after starting ART was 8.5% (IQR: 4.2-19.7%). Strategies to reduce loss to follow-up included outreach teams, community-based organizations and checking death registry data. Implementation of all three strategies substantially reduced losses to follow-up (OR: 0.17; 95% CI: 0.15-0.20). CONCLUSION: The quality of the data collected and the retention of patients in ART treatment programmes are unsatisfactory for many sites involved in the scale-up of ART in resource-limited settings, mainly because of insufficient staff trained to manage data and trace patients lost to follow-up.

Models for intensive care training. A European perspective.

The diversity of European culture is reflected in its healthcare training programs. In intensive care medicine (ICM), the differences in national training programs were so marked that it was unlikely that they could produce specialists of equivalent skills. The Competency-Based Training in Intensive Care Medicine in Europe (CoBaTrICE) program was established in 2003 as a Europe-based worldwide collaboration of national training organizations to create core competencies for ICM using consensus methodologies to establish common ground. The group's professional and research ethos created a social identity that facilitated change. The program was easily adaptable to different training structures and incorporated the voice of patients and relatives. The CoBaTrICE program has now been adopted by 15 European countries, with another 12 countries planning to adopt the training program, and is currently available in nine languages, including English. ICM is now recognized as a primary specialty in Spain, Switzerland, and the UK. There are still wide variations in structures and processes of training in ICM across Europe, although there has been agreement on a set of common program standards. The combination of a common "product specification" for an intensivist, combined with persisting variation in the educational context in which competencies are delivered, provides a rich source of research inquiry. Pedagogic research in ICM could usefully focus on the interplay between educational interventions, healthcare systems and delivery, and patient outcomes, such as including whether competency-based program are associated with lower error rates, whether communication skills training is associated with greater patient and family satisfaction, how multisource feedback might best be used to improve reflective learning and teamworking, or whether increasing the proportion of specialists trained in acute care in the hospital at weekends results in better patient outcomes.

Individual Video Training - Entwicklung einer nationalen Infrastruktur für Video-unterstütztes Lernen

Video-basiertes Lernen ist besonders effektiv, wo es um Fertigkeiten und Verhalten geht. Videoaufzeichnungen von Gesprächen, Unterrichtssituationen oder der Durchführung praktischer Tätigkeiten wie dem Nähen einer Wunde erlauben es den Ausführenden, ihren Peers und ihren Tutoren, die Qualität der Leistung zu beurteilen und Anregungen zur Verbesserung zu formulieren. Wissend um den grossen didaktischen Wert von Videoaufzeichnungen haben sich vier Pädagogische Hochschulen (Zürich, Freiburg, Thurgau, Luzern) und zwei Medizinische Fakultäten (Bern, Lausanne) zusammen getan, um eine nationale Infrastruktur für Video-unterstütztes Lernen anzustossen. Ziel was es, ein System zu entwickeln, das einfach zu bedienen ist, bei dem viele Arbeitsschritte automatisiert sind und das die Videos im Internet bereit stellt. Zusammen mit SWITCH, der nationalen IT-Support-Organisation der Schweizer Hochschulen, wurde basierend auf den vorbestehenden Technologien AAI und SWITCHcast das Programm iVT (Individual Video Training) entwickelt. Die Integration des nationalen Single Logon System AAI (Authentification and Authorization Infrastructure) erlaubt es, die Videos mit dem jeweiligen User eindeutig zu verknüpfen, so dass die Videos nur für diesen User im Internet zugänglich sind. Mit dem Podcast-System SWITCHcast können Videos automatisch ins Internet hochgeladen und bereit gestellt werden. Es wurden je ein Plugin für die Learning Management Systeme ILIAS (PH Zürich, Uni Bern) und Moodle (Uni Lausanne) entwickelt. Dank dieser Plugins werden die Videos in den jeweiligen LMS verfügbar gemacht. Der Einsatz von iVT ist beim Kommunikationstraining unserer Medizinstudierenden in Bern inzwischen Standard. Das Login gilt gleichzeitig als Beleg für das Testat. Studierende, die keine Videoaufzeichnung wünschen, können diese nach dem Login stoppen. Bis anhin ist das Betrachten der Videos freiwillig. Szenarios mit Peer Feedback sind geplant. Eine entsprechende Erweiterung des Systems um gegenseitige Annotationsmöglichkeiten besteht bereits und wird fortlaufend weiterentwickelt.

How Cantonal Education Systems in Switzerland Promote Gender-Typical School-to-Work Transitions

The paper asks how cantonal education systems in Switzerland promote gender-typed school-to-work transitions and gender segregation at work. Data from the Swiss TREE youth panel study is used to analyse the impact of cantonal provision of vocational education and training (VET) on gender-typical educational trajectories. The findings show that education systems with higher VET rates have higher allocations of men in gender-(male-) typical occupational careers. The paper concludes that the pronounced and persistent gender segregation on the Swiss labor market is partly due to a prominent VET system, which urges early gender-typed occupational career decisions.

Educational Systems and Gender Segregation in Education: A Three-Country Comparison of Germany, Norway and Canada

How do institutional settings and their embedded policy principles affect gender-typed enrolment in educational programmes? Based on gender-sensitive theories on career choice, we hypothesised that gender segregation in education is higher with a wider range of offers of vocational programmes. By analysing youth survey and panel data, we tested this assumption for Germany, Norway and Canada, three countries whose educational systems represent a different mix of academic, vocational and universalistic education principles. We found that vocational programmes are considerably more gender-segregated than are academic (e.g. university) programmes. Men, more so than women, can avoid gender-typed programmes by passing on to a university education. This in turn means that as long as their secondary school achievement does not allow for a higher education career, they have a higher likelihood of being allocated to male-typed programmes in the vocational education and training (VET) system. In addition, social background and the age at which students have to choose educational offers impact on the transition to gendered educational programmes. Overall, gender segregation in education is highest in Germany and the lowest in Canada. We interpret the differences between these countries with respect to the constellations of educational principles and policies in the respective countries.

Simple training tool is insufficient for appropriate diagnosis and treatment of malnutrition: A pre-post intervention study in a tertiary center.

OBJECTIVES To improve malnutrition awareness and management in our department of general internal medicine; to assess patients' nutritional risk; and to evaluate whether an online educational program leads to an increase in basic knowledge and more frequent nutritional therapies. METHODS A prospective pre-post intervention study at a university department of general internal medicine was conducted. Nutritional screening using Nutritional Risk Score 2002 (NRS 2002) was performed, and prescriptions of nutritional therapies were assessed. The intervention included an online learning program and a pocket card for all residents, who had to fill in a multiple-choice questions (MCQ) test about basic nutritional knowledge before and after the intervention. RESULTS A total of 342 patients were included in the preintervention phase, and 300 were in the postintervention phase. In the preintervention phase, 54.1% were at nutritional risk (NRS 2002 ≥3) compared with 61.7% in the postintervention phase. There was no increase in the prescription of nutritional therapies (18.7% versus 17.0%). Forty-nine and 41 residents (response rate 58% and 48%) filled in the MCQ test before and after the intervention, respectively. The mean percentage of correct answers was 55.6% and 59.43%, respectively (which was not significant). Fifty of 84 residents completed the online program. The residents who participated in the whole program scored higher on the second MCQ test (63% versus 55% correct answers, P = 0.031). CONCLUSIONS Despite a high ratio of malnourished patients, the nutritional intervention, as assessed by nutritional prescriptions, is insufficient. However, the simple educational program via Internet and usage of NRS 2002 pocket cards did not improve either malnutrition awareness or nutritional treatment. More sophisticated educational systems to fight malnutrition are necessary.