What are tests for? The implications of stuttering steps along the patient pathway

This article explores the implications of how US family physicians make decisions about ordering diagnostic tests for their patients. Data is based on a study of 256 physicians interviewed after viewing a video vignette of a presenting patient. The qualitative analysis of 778 statements relating to trustworthiness of evidence for their decision making, the use of any kind of technology and diagnostic testing suggests a range of internal and external constraints on physician decision making. Test-ordering for family physicians in the United States is significantly influenced by both hidden cognitive processes related to the physician's calculation of patient resources and a health insurance system that requires certain types of evidence in order to permit further tests or particular interventions. The consequence of the need for physicians to meet multiple forms of proof that may not always relate to relevant treatment delays a diagnosis and treatment plan agreed not only by the physician and patient but also the insurance company. This results in a patient journey that is made up of stuttering steps to a confirmed diagnosis and treatment undermining patient-centred practice, compromising patient care, constraining physician autonomy and creating additional expense. © 2014 Elsevier Ltd.

The role of self-regulation as a meta-competency in developing leaders: a longitudinal field experimental study

The question of how to develop leaders so that they are more effective in a variety of situations, roles and levels has inspired a voluminous amount of research. While leader development programs such as executive coaching and 360-degree feedback have been widely practiced to meet this demand within organisations, the research in this area has only scratched the surface. Drawing from the past literature and leadership practices, the current research conceptualised self-regulation, as a metacompetency that would assist leaders to further develop the specific competencies needed to perform effectively in their leadership role, leading to an increased rating of leader effectiveness and to enhanced group performance. To test this conceptualisation, a longitudinal field experimental study was conducted across ten months with a pre- and two post-test intervention designs with a matched control group. This longitudinal field experimental compared the difference in leader and team performance after receiving self-regulation intervention that was delivered by an executive coach. Leaders in experimental group also received feedback reports from 360-degree feedback at each stage. Participants were 40 leaders, 155 followers and 8 supervisors. Leaders’ performance was measured using a multi-source perceptual measure of leader performance and objective measures of team financial and assessment performance. Analyses using repeated measure of ANCOVA on pre-test and two post-tests responses showed a significant difference between leader and team performance between experimental and control group. Furthermore, leader competencies mediated the relationship between self-regulation and performance. The implications of these findings for the theory and practice of leadership development training programs and the impact on organisational performance are discussed.

Statnote 23: Non-parametric analysis of variance (ANOVA)

To carry out an analysis of variance, several assumptions are made about the nature of the experimental data which have to be at least approximately true for the tests to be valid. One of the most important of these assumptions is that a measured quantity must be a parametric variable, i.e., a member of a normally distributed population. If the data are not normally distributed, then one method of approach is to transform the data to a different scale so that the new variable is more likely to be normally distributed. An alternative method, however, is to use a non-parametric analysis of variance. There are a limited number of such tests available but two useful tests are described in this Statnote, viz., the Kruskal-Wallis test and Friedmann’s analysis of variance.

The clinical utility of the middle latency and 40Hz auditory evoked potentials in audiological electrodiagnosis

The two elcctrophysiological tests currently favoured in the clinical measurement of hearing threshold arc the brainstorm evoked potential (BAEP) and the slow vertex response (SVR). However, both tests possess disadvantages. The BAEP is the test of choice in younger patients as it is stable at all levels of arousal, but little information has been obtained to date at a range of frequencies. The SVR is frequency specific but is unreliable in certain adult subjects and is unstable during sleep or in young children. These deficiencies have prompted research into a third group of potentials, the middle latency response (MLR) and the 40HZ responses. This research has compared the SVR and 40HZ response in waking adults and reports that the 40HZ test can provide a viable alternative to the SVR provided that a high degree of subject relaxation is ensured. A second study examined the morphology of the MLR and 40HZ during sleep. This work suggested that these potentials arc markedly different during sleep and that methodological factors have been responsible for masking these changes in previous studies. The clinical possibilities of tone pip BAEPs were then examined as these components were proved to be the only stable responses present in sleep. It was found that threshold estimates to 5OOHz, lOOOHz and 4000Hz stimuli could be made to within 15dBSL in most cases. A final study looked more closely at methods of obtaining frequency specific information in sleeping subjects. Threshold estimates were made using established BAEP parameters and this was compared to a 40HZ procedure which recorded a series of BAEPs over a 100msec. time sweep. Results indicated that the 40mHz procedure was superior to existing techniques in estimating threshold to low frequency stimuli. This research has confirmed a role for the MLR and 40Hz response as alternative measures of hearing capability in waking subjects and proposes that the 40Hz technique is useful in measuring frequency specific thresholds although the responses recorded derive primarily from the brainstem.

The influence of patient's age on clinical decision-making about coronary heart disease in the USA and the UK

This paper examines UK and US primary care doctors' decision-making about older (aged 75 years) and midlife (aged 55 years) patients presenting with coronary heart disease (CHD). Using an analytic approach based on conceptualising clinical decision-making as a classification process, it explores the ways in which doctors' cognitive processes contribute to ageism in health-care at three key decision points during consultations. In each country, 56 randomly selected doctors were shown videotaped vignettes of actors portraying patients with CHD. The patients' ages (55 or 75 years), gender, ethnicity and social class were varied systematically. During the interviews, doctors gave free-recall accounts of their decision-making. The results do not establish that there was substantial ageism in the doctors' decisions, but rather suggest that diagnostic processes pay insufficient attention to the significance of older patients' age and its association with the likelihood of co-morbidity and atypical disease presentations. The doctors also demonstrated more limited use of 'knowledge structures' when diagnosing older than midlife patients. With respect to interventions, differences in the national health-care systems rather than patients' age accounted for the differences in doctors' decisions. US doctors were significantly more concerned about the potential for adverse outcomes if important diagnoses were untreated, while UK general practitioners cited greater difficulty in accessing diagnostic tests.

Intentional forgetting in dysphoria:investigating the inhibitory effects of thought substitution using independent cues

Background Individuals with clinical and subclinical depression (dysphoria) exhibit problems intentionally forgetting unwanted memories on the think/no-think (TNT) paradigm (Anderson & Green, 2001). However, providing substitute words to think about instead of the to-be-forgotten targets can improve forgetting in depressed patients. Objectives To determine if thought substitution can enhance forgetting in dysphoric participants and to examine the potential mechanisms (blocking or inhibition) that might underpin successful forgetting. Methods Thirty-six dysphoric and 36 non-dysphoric participants learned neutral word-pairs and then practiced responding with the targets to some cues (think trials) and suppressing responses to others (no think trials). Half the participants were provided with substitute words to recall instead of the original targets (aided suppression) and half were simply told to avoid thinking about the targets (unaided suppression). Finally, participants completed two recall tests for the targets; one cued with the original probes and one with independent probes. Results Regardless of suppression condition (aided or unaided), dysphoric participants exhibited impaired forgetting, relative to their non-dysphoric counterparts, but only when cued with the original probes. Furthermore, higher depression scores were associated with poorer forgetting. In the aided condition, successful forgetting was observed on both the original and independent probe tasks, which supports the inhibitory account of thought substitution. Limitations Non-clinical status of the dysphoric participants was not confirmed using a validated measure. Conclusions Findings do not support the utility of thought substitution as a method of improving the forgetting in depressed participants, but do support the inhibition account of thought substitution.

Intrapartum tests for group B streptococcus:accuracy and acceptability of screening

Objective: To assess the accuracy and acceptability of polymerase chain reaction (PCR) and optical immunoassay (OIA) tests for the detection of maternal group B streptococcus (GBS) colonisation during labour, comparing their performance with the current UK policy of risk factor-based screening. Design Diagnostic test accuracy study. Setting and population Fourteen hundred women in labour at two large UK maternity units provided vaginal and rectal swabs for testing. Methods The PCR and OIA index tests were compared with the reference standard of selective enriched culture, assessed blind to index tests. Factors influencing neonatal GBS colonisation were assessed using multiple logistic regression, adjusting for antibiotic use. The acceptability of testing to participants was evaluated through a structured questionnaire administered after delivery. Main outcome measures The sensitivity and specificity of PCR, OIA and risk factor-based screening. Results Maternal GBS colonisation was 21% (19-24%) by combined vaginal and rectal swab enriched culture. PCR test of either vaginal or rectal swabs was more sensitive (84% [79-88%] versus 72% [65-77%]) and specific (87% [85-89%] versus 57% [53-60%]) than OIA (P <0.001), and far more sensitive (84 versus 30% [25-35%]) and specific (87 versus 80% [77-82%]) than risk factor-based screening (P <0.001). Maternal antibiotics (odds ratio, 0.22 [0.07-0.62]; P = 0.004) and a positive PCR test (odds ratio, 29.4 [15.8-54.8]; P <0.001) were strongly related to neonatal GBS colonisation, whereas risk factors were not (odds ratio, 1.44 [0.80-2.62]; P = 0.2). Conclusion Intrapartum PCR screening is a more accurate predictor of maternal and neonatal GBS colonisation than is OIA or risk factor-based screening, and is acceptable to women. © RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology.