Medical Education - Research Publications
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ItemNo Preview AvailablePrescribing oxygen: An audit of prescribing and delivery practices at two tertiary hospitals in Melbourne, Australia(Wiley Online Library, 2021)Background and Aims: Over-oxygenation in COPD patients can result in adverse outcomes. The use of specific oxygen saturation targets in COPD has been associated with less acidosis, a lower requirement for assisted ventilation, and reduced mortality. Our study reviews current practices of both oxygen prescription and delivery for patients admitted at two tertiary hospitals with an exacerbation of COPD. Methods: This retrospective audit included all admissions at two tertiary hospitals with a primary diagnosis of exacerbation of COPD over 6 months (April to September 2020). Medical records were reviewed to determine how many had documented target SpO2 ranges and how concordant these were with the Thoracic Society of Australia and New Zealand guidelines (SpO2 range 88% to 92% in COPD). For those with documented SpO2 ranges, we determined the percentage of recorded SpO2 levels that were below, above and within the target range. Results: 312 admissions for exacerbation of COPD were reviewed. Target SpO2 goals were documented for 57% of admissions (N=178), of which 77% (N=137) were consistent with current guidelines. Of those with a documented SpO2 range, only 75.4% of recorded SpO2 readings were within range, with 2.3% falling below and 22.3% above range. Conclusions: Our results highlight underutilisation of SpO2 targets in patients with COPD, as well as frequent over-oxygenation despite documented targets.
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ItemSerum potassium abnormalities in chronic kidney disease: prevalence, patient characteristics and clinical outcomes(WILEY, 2021-11)BACKGROUND: Abnormalities in serum potassium are a well known complication of chronic kidney disease (CKD), but little is known about their impact on inpatient outcomes. AIMS: To better understand the role of dyskalaemia in hospital in-patients, we assessed the epidemiology of potassium disorders among CKD patients, and the association between admission potassium and inpatient mortality or intensive care unit (ICU) requirement. METHODS: This retrospective hospital-based cohort study (n = 11 156) included patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 admitted to Austin Health between 2014 and 2018 and who had an admission potassium value. Dialysis patients or those with a renal transplant were excluded. Multivariate logistic analysis was conducted to identify factors associated with hyperkalaemia (≥5.5 mmol/L) and hypokalaemia (<3.5 mmol/L). Odds ratios for inpatient mortality and ICU admission between potassium categories were obtained by multivariate regression with adjustments for demographics, renal function and comorbidities. RESULTS: Hyperkalaemia and hypokalaemia were present in 6.86% and 2.94% of hospital admissions respectively. In multivariate regression male sex, lower eGFR, diabetes and cardiac failure were associated with higher odds of hyperkalaemia. Thiazide diuretics, loop diuretics, infectious disease and endocrine pathology were associated with higher odds of hypokalaemia. A U-shaped association was noted between potassium and inpatient mortality. Potassium <4.0 mmol/L and ≥5.0 mmol/L was associated with increased mortality. Only patients with potassium ≥5.5 mmol/L had increased ICU admission risk. CONCLUSION: Derangements in potassium frequently occur in CKD inpatients and are independently associated with higher mortality and ICU requirement. Further studies are required to determine whether interventions to maintain normokalaemia improve outcomes in this population.
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ItemRethinking Assessment Design: Evidence-Informed Strategies to Boost Educational Impact in the Anatomical Sciences(WILEY, 2021-05)University assessment is in the midst of transformation. Assessments are no longer designed solely to determine that students can remember and regurgitate lecture content, nor in order to rank students to aid with some future selection process. Instead, assessments are expected to drive, support, and enhance learning and to contribute to student self-assessment and development of skills and attributes for a lifetime of learning. While traditional purposes of certifying achievement and determining readiness to progress remain important, these new expectations for assessment can create tensions in assessment design, selection, and deployment. With the recognition of these tensions, three contemporary approaches to assessment in medical education are described. These approaches include careful consideration of the educational impact of assessment-before, during (test or recall enhanced learning) and after assessments; development of student (and staff) assessment literacy; and planning of cohesive systems of assessment (with a range of assessment tools) designed to assess the various competencies demanded of future graduates. These approaches purposefully straddle the cross purposes of assessment in modern health professions education. The implications of these models are explored within the context of medical education and then linked with contemporary work in the anatomical sciences in order to highlight current synergies and potential future innovations when using evidence-informed strategies to boost the educational impact of assessments.
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ItemDetermining Expected Research Skills of Medical Students on Graduation: a Systematic Review(Springer, 2020-12)BACKGROUND: Global interest in research skills in undergraduate medical education is growing. There is no consensus regarding expected research skills of medical students on graduation. We conducted a systematic review to determine the aims and intended learning outcomes (ILOs) of mandatory research components of undergraduate medical curricula incorporating the teaching, assessment, and evaluation methods of these programs. METHODS: Using the PRISMA protocol, MEDLINE and ERIC databases were searched with keywords related to "medical student research programs" for relevant articles published up until February 2020. Thematic analysis was conducted according to student experience/reactions, mentoring/career development, and knowledge/skill development. RESULTS: Of 4880 citations, 41 studies from 30 institutions met the inclusion criteria. Programs were project-based in 24 (80%) and coursework only-based in 6 (20%). Program aims/ILOs were stated in 24 programs (80%). Twenty-seven different aims/ILOs were identified: 19 focused on knowledge/skill development, 4 on experience/reactions, and 4 on mentoring/career development. Project-based programs aimed to provide an in-depth research experience, foster/increase research skills, and critically appraise scientific literature. Coursework-based programs aimed to foster/apply analytical skills for decision-making in healthcare and critically appraise scientific literature. Reporting of interventions was often incomplete, short term, and single institution. There was poor alignment between aims, teaching, assessment, and evaluation methods in most. CONCLUSIONS: The diversity of teaching programs highlights challenges in defining core competencies in research skills for medical graduates. Incomplete reporting limits the evidence for effective research skills education; we recommend those designing and reporting educational interventions adopt recognized educational reporting criteria when describing their findings. Whether students learn by "doing", "proposing to do", or "critiquing", good curriculum design requires constructive alignment between teaching, assessment, and evaluation methods, aims, and outcomes. Peer-reviewed publications and presentations only evaluate one aspect of the student research experience.
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ItemNo Preview AvailableAutomated Best Practice Alerts Improved Treatment Initiation Post Hip Fracture(Australian and New Zealand Bone and Mineral Society, 2021)Background: An initial fragility fracture increases risk of subsequent fracture two- to three-fold; the highest risk is evident within the first two years (1). Despite the known benefit in prompt treatment post-fracture, underutilisation of anti-resorptive medications is widespread (2). The Australian & New Zealand Hip Fracture Registry shows hip fractures, the fracture with the highest morbidity and mortality, remain sub optimally managed (3, 4). After consultation with stakeholders, Best Practice Alerts (BPA) were implemented with a built-in treatment pathway to improve Vitamin D testing, inpatient Vitamin D treatment, and pre-discharge anti-resorptive treatment initiation in patients with hip fracture. Methods: Hip fracture admission pre-BPA implementation was captured via the REStORing health of acutely unwell adulTs cohort (May 2019 – March 2020), and via electronic medical record post-BPA implementation (March - July 2021). Three BPAs were implemented: 1) order for Vitamin D testing triggered by inpatient hip fracture diagnosis, 2) order for colecalciferol triggered by vitamin D result ≤50 nmol/L AND vitamin D not already charted, 3) order for anti-resorptive treatment triggered by the discharge summary. The introduction of BPAs was supported by targeted education of stakeholders. Patient discharge medications were compared pre- and post-BPA implementation. Results: BPA fired 572 times in 75 hip fracture patients [age (mean ± SD) 79.5±8.9yrs, 61.3% female]. Parameters which did not differ pre- (n=58) and post-implementation were vitamin D testing (96.6% vs 97.3%), vitamin D level (62.5 vs 68.3 nmol/L), vitamin D treatment at discharge (75.9% vs 88%) and anti-resorptive treatment on admission (15.5% vs 20%). Anti-resorptive treatment rate on discharge increased 3-fold post-BPA implementation (21% vs 68%, p=<0.001). Conclusion: Automated BPA with an incorporated evidence-based treatment pathway provides a powerful tool to assist medical staff in overcoming the secondary fracture prevention care gap. Further fine-tuning will reduce redundant firing of BPA and avoid “alert fatigue”.
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ItemNo Preview AvailableChanging anti-resorptive prescription rates in the last five years(Australian and New Zealand Bone and Mineral Society, 2021)Background: Osteoporosis or osteopaenia affect approximately six million Australians aged > 50 years, resulting in fracture-related morbidity and mortality. The treatment dosing schedule, duration and effects after treatment cessation vary due to the different actions of the anti-resorptive medications. Importantly, a rapid increase in bone turnover markers and reduction in bone mineral density can be seen following denosumab cessation (1). Vertebral fractures have been observed eight months following the last denosumab dose due to the rebound increase of bone resorption, in contrast to bisphosphonates’ persistent skeletal action despite cessation (2). Lockdown of citizen movement in Australia occurred during the COVID-19 pandemic in 2020 causing disruption to healthcare and in-person reviews. Aim: To examine national prescribing rates from 2016 to 2021 of denosumab, alendronate and risedronate. Method: This retrospective audit analysed prescribing rates of anti-resorptive medications. Data was sourced from The Pharmaceutical Benefits Scheme ‘Date of Supply’. Time-based trends were analysed by two methods: a polynomial (quadratic) line of best fit (R2 = 0.8639) and an interrupted time series using a quasipoisson distribution, with comparison made between pre- and post-COVID-19 onset (March 2020) periods. Results: Prescription rate of denosumab increased from 2016 to 2021. The rate has been steadily slowing with intensification of this trend noted post the onset of the COVID-19 pandemic (Figure 1). The long-term rates of prescription of alendronate and risedronate have decreased, with a notable inversion in this trend following March 2020 (Figure 2). Conclusion: The rate of denosumab prescriptions has slowed, more so following March 2020. This could be related to decreased new starts and/or decreased treatment continuation. Future research is required to determine if higher rates of rebound-associated fractures are occurring. Clinicians are urged to ensure that a strict 6 monthly dosing interval for denosumab is employed to mitigate the risk of rebound fractures.
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ItemNo Preview AvailableLower limb amputations in patients with diabetes-related foot complications in the COVID-19 pandemic(Endocrine Society of Australia, 2021)
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