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1.  How hyper are we? A look at hypermedia management in academic health sciences libraries. 
Advances in instruction-delivery technology have a direct impact on academic media centers. New technology challenges librarians philosophically, financially, and ethically to provide access to information and instructional systems. Each institution has a unique set of circumstances governing decisions to provide access to hypermedia. If patron needs are met satisfactorily through labs outside the library, it may not be necessary for the library to incorporate hypermedia into its collection. Other library media centers may serve as a main point of access, or a substantial alternative computing resource may exist in departments or professional schools. Regardless of which route is taken, hypermedia is a viable instructional delivery system and can coexist with traditional services. Future studies on various aspects of hypermedia and multimedia management should be encouraged. Academic health sciences librarians would benefit from the study of hypermedia and multimedia collection-development policies, equipment, and personnel management. As computer networking of multimedia and image databases becomes available, it will be interesting to see the role academic health sciences libraries assume in integrating these data-bases with traditional information-delivery systems. Changing technology and instructional methods will affect budgets as well as library relationships with academic departments and computing centers.
PMCID: PMC225732  PMID: 8428192
2.  Interactive Methods for Teaching Action Potentials, an Example of Teaching Innovation from Neuroscience Postdoctoral Fellows in the Fellowships in Research and Science Teaching (FIRST) Program 
Acquiring a faculty position in academia is extremely competitive and now typically requires more than just solid research skills and knowledge of one’s field. Recruiting institutions currently desire new faculty that can teach effectively, but few postdoctoral positions provide any training in teaching methods. Fellowships in Research and Science Teaching (FIRST) is a successful postdoctoral training program funded by the National Institutes of Health (NIH) providing training in both research and teaching methodology. The FIRST program provides fellows with outstanding interdisciplinary biomedical research training in fields such as neuroscience. The postdoctoral research experience is integrated with a teaching program which includes a How to Teach course, instruction in classroom technology and course development and mentored teaching. During their mentored teaching experiences, fellows are encouraged to explore innovative teaching methodologies and to perform science teaching research to improve classroom learning. FIRST fellows teaching neuroscience to undergraduates have observed that many of these students have difficulty with the topic of neuroscience. Therefore, we investigated the effects of interactive teaching methods for this topic. We tested two interactive teaching methodologies to determine if they would improve learning and retention of this information when compared with standard lectures. The interactive methods for teaching action potentials increased understanding and retention. Therefore, FIRST provides excellent teaching training, partly by enhancing the ability of fellows to integrate innovative teaching methods into their instruction. This training in turn provides fellows that matriculate from this program more of the characteristics that hiring institutions desire in their new faculty.
PMCID: PMC3592690  PMID: 23493377
action potential; postdoctoral fellowship; interactive teaching; pedagogy; neuroscience; mentoring
3.  E-Learning as New Method of Medical Education 
Acta Informatica Medica  2008;16(2):102-117.
CONFLICT OF INTEREST: NONE DECLARED
Distance learning refers to use of technologies based on health care delivered on distance and covers areas such as electronic health, tele-health (e-health), telematics, telemedicine, tele-education, etc. For the need of e-health, telemedicine, tele-education and distance learning there are various technologies and communication systems from standard telephone lines to the system of transmission digitalized signals with modem, optical fiber, satellite links, wireless technologies, etc. Tele-education represents health education on distance, using Information Communication Technologies (ICT), as well as continuous education of a health system beneficiaries and use of electronic libraries, data bases or electronic data with data bases of knowledge. Distance learning (E-learning) as a part of tele-education has gained popularity in the past decade; however, its use is highly variable among medical schools and appears to be more common in basic medical science courses than in clinical education. Distance learning does not preclude traditional learning processes; frequently it is used in conjunction with in-person classroom or professional training procedures and practices. Tele-education has mostly been used in biomedical education as a blended learning method, which combines tele-education technology with traditional instructor-led training, where, for example, a lecture or demonstration is supplemented by an online tutorial. Distance learning is used for self-education, tests, services and for examinations in medicine i.e. in terms of self-education and individual examination services. The possibility of working in the exercise mode with image files and questions is an attractive way of self education. Automated tracking and reporting of learners’ activities lessen faculty administrative burden. Moreover, e-learning can be designed to include outcomes assessment to determine whether learning has occurred. This review article evaluates the current status and level of tele-education development in Bosnia and Herzegovina outlining its components, faculty development needs for implementation and the possibility of its integration as official learning standard in biomedical curricula in Bosnia and Herzegovina. Tele-education refers to the use of information and communication technologies (ICT) to enhance knowledge and performance. Tele-education in biomedical education is widely accepted in the medical education community where it is mostly integrated into biomedical curricula forming part of a blended learning strategy. There are many biomedical digital repositories of e-learning materials worldwide, some peer reviewed, where instructors or developers can submit materials for widespread use. First pilot project with the aim to introduce tele-education in biomedical curricula in Bosnia and Herzegovina was initiated by Department for Medical Informatics at Medical Faculty in Sarajevo in 2002 and has been developing since. Faculty member’s skills in creating tele-education differ from those needed for traditional teaching and faculty rewards must recognize this difference and reward the effort. Tele-education and use of computers will have an impact of future medical practice in a life long learning. Bologna process, which started last years in European countries, provide us to promote and introduce modern educational methods of education at biomedical faculties in Bosnia and Herzegovina. Cathedra of Medical informatics and Cathedra of Family medicine at Medical Faculty of University of Sarajevo started to use Web based education as common way of teaching of medical students. Satisfaction with this method of education within the students is good, but not yet suitable for most of medical disciplines at biomedical faculties in Bosnia and Herzegovina.
doi:10.5455/aim.2008.16.102-117
PMCID: PMC3789161  PMID: 24109154
Medical education; Distance learning; Bosnia and Herzegovina
4.  Perceptions and Use of iPad Technology by Pharmacy Practice Faculty Members 
Objectives. To explore the potential of tablet technology to address the specific workload challenges of pharmacy practice faculty members and to evaluate tablet usage after a department-wide iPad initiative.
Methods. After conducting a needs assessment to determine pharmacy faculty attitudes towards tablet technology and to identify potential usage scenarios, all faculty members in a department of pharmacy practice received an iPad. After iPad distribution, training sessions and virtual tutorials were provided. An anonymous survey was administered to evaluate the pilot.
Results. The needs assessment survey revealed positive attitudes towards iPad technology, identified use scenarios, and led to a department-wide iPad pilot program. Most faculty members used iPads for connectivity with students (86%), paper/project annotation (68%), assessment (57%), and demonstration of tools used in practice (36%). For teaching, 61% of faculty members used iPads in seminars/laboratories, 57% used iPads in the experiential setting, and 43% used iPads in the classroom. Use of iPads for patient-care activities varied and depended on site support for mobile technology. The 23 faculty members with external practice sites used iPads to a greater extent and had more positive attitudes towards this technology compared with campus-based faculty members.
Conclusion. Integration of tablet technology into the pharmacy education setting resulted in faculty-reported increased productivity and decreased paper waste. It also allowed faculty members to experiment with new teaching strategies in the classroom and experiential setting. Administrators at institutions exploring the use of tablet technology should allocate resources based on faculty needs and usage patterns.
doi:10.5688/ajpe78352
PMCID: PMC3996384  PMID: 24761013
instructional technology; pharmacy faculty; health care; iPad
5.  Shoestring Budgets, Band-Aids, and Team Work: Challenges and Motivators in the Development of a Web-Based Resource for Undergraduate Clinical Skills Teaching 
Background
Learning how to conduct a medical interview and perform a physical examination is fundamental to the practice of medicine; however, when this project began, the methods used to teach these skills to medical students at the University of Toronto (U of T) had not changed significantly since the early 1990s despite increasing outpatient care, shorter hospital stays, and heavy preceptor workloads. In response, a Web-based clinical skills resource was developed for the first-year undergraduate medical course—The Art and Science of Clinical Medicine I (ASCM I).
Objectives
This paper examines our experiences with the development of the ASCM I website and details the challenges and motivators inherent in the production of a Web-based, multimedia medical education tool at a large Canadian medical school.
Methods
Interviews and a focus group were conducted with the development team to discover the factors that positively and negatively affected the development process.
Results
Motivating factors included team attributes such as strong leadership and judicious use of medical students and faculty volunteers as developers. Other motivators included a growing lack of instructional equivalency across diverse clinical teaching sites and financial and resource support by the Faculty of Medicine. Barriers to development included an administrative environment that did not yet fully incorporate information technology into its teaching vision and framework, a lack of academic incentive for faculty participation, and inadequate technical support, space, and equipment.
Conclusions
The success of electronic educational resources such as the ASCM I website has caused a significant cultural shift within the Faculty of Medicine, resulting in the provision of more space, resources, and support for IT endeavours in the undergraduate medical curriculum.
doi:10.2196/jmir.7.2.e14
PMCID: PMC1550644  PMID: 15914461
Undergraduate medical education; Internet; clinical skills; medical history taking; teaching methods; training techniques; qualitative research; focus groups; interviews
6.  A collaborative institutional model for integrating computer applications in the medical curriculum. 
The introduction and promotion of information technology in an established medical curriculum with existing academic and technical support structures poses a number of challenges. The UNC School of Medicine has developed the Taskforce on Educational Applications in Medicine (TEAM), to coordinate this effort. TEAM works as a confederation of existing research and support units with interests in computers and education, along with a core of interested faculty with curricular responsibilities. Constituent units of the TEAM confederation include the medical center library, medical television studios, basic science teaching laboratories, educational development office, microcomputer and network support groups, academic affairs administration, and a subset of course directors and teaching faculty. Among our efforts have been the establishment of (1) a mini-grant program to support faculty initiated development and implementation of computer applications in the curriculum, (2) a symposium series with visiting speakers to acquaint faculty with current developments in medical informatics and related curricular efforts at other institution, (3) 20 computer workstations located in the multipurpose teaching labs where first and second year students do much of their academic work, (4) a demonstration center for evaluation of courseware and technologically advanced delivery systems. The student workstations provide convenient access to electronic mail, University schedules and calendars, the CoSy computer conferencing system, and several software applications integral to their courses in pathology, histology, microbiology, biochemistry, and neurobiology. The progress achieved toward the primary goal has modestly exceeded our initial expectations, while the collegiality and interest expressed toward TEAM activities in the local environment stand as empirical measures of the success of the concept.
PMCID: PMC2247631  PMID: 1807705
7.  SOMAS-URM: The Evolution of a Mentoring and Summer Research Program 
The need to enhance recruitment and retention of students in the sciences to strengthen the economic and scientific foundation of the United States was recently underscored by the National Science Board. The SOMAS Program (Support Of Mentors And their Students) addresses this need using a two-pronged strategy: 1) Junior faculty receive mentoring and instruction in launching research programs that engage student collaborators; and 2) College students are introduced to discovery in the neurosciences by conducting original research with their professors. Junior faculty from predominantly undergraduate institutions are invited to submit applications to obtain summer research support for undergraduate students who will spend 10 weeks collaborating with the faculty member on projects of common interest. Awards cover a travel and a supply budget, summer student housing, as well as faculty and student stipends. The faculty mentors and their students are to use the travel support to attend the joint Annual Meetings of the Society for Neuroscience (SfN) and the Faculty for Undergraduate Neuroscience (FUN). Faculty Awardees are required to participate in the Survival Skills and Ethics Workshop held at the SfN Meeting to prepare them to write grants aimed at supporting their research programs. Students are to present their summer research findings at the FUN Poster Session held jointly with the SfN Meeting. Students are also required to attend Survival Skills Workshop sessions that focus on ethics in research and that provide tips on applying to graduate school. The SOMAS-URM Program presently emphasizes recruitment and retention of underrepresented groups to enhance participation in scientific discovery by the full range of the American population.
PMCID: PMC3592711  PMID: 23493419
funding program; mentorship; predominantly undergraduate institution; undergraduate student
8.  The Information Commons: a model for (physical) digital resource centers. 
Since its planning, construction, and opening in 1996, the Information Commons, located in The University of Iowa's Hardin Library for the Health Sciences, has served as a common ground for self-directed learning, information research, hands-on class sessions, and multimedia development. Initiatives launched from the Information Commons not only have helped increase the visibility of Hardin Library as an environment well equipped to support traditional research and education needs, but have promoted the library as a campus leader and viable partner in planning and delivering digital technologies effectively. Ongoing initiatives have focused on better integrating the library's services and resources with the curricula and research needs of the university's health sciences units. This paper describes the facility, its programmatic elements, and its impact on education, communication, and technology trends in an academic health sciences setting. Particular attention is paid to initiatives launched during the first two years of operation. This paper also discusses plans for expansion of the facility.
PMCID: PMC226454  PMID: 9803303
9.  The Department of Veterans Affairs National Quality Scholars Fellowship Program 
The Department of Veterans Affairs National Quality Scholars Fellowship Program (VAQS) was established in 1998 as a post-graduate medical education fellowship to train physicians in new methods of improving the quality and safety of health care for Veterans and the nation. The VAQS curriculum is based on adult learning theory, with a national core curriculum of face-to-face components, technologically mediated distance learning components, and a unique local curriculum that draws from the strengths of regional resources.
VAQS has established strong ties with other VA programs. Fellows’ research and projects are integrated with local and regional VA leaders’ priorities, enhancing the relevance and visibility of the fellows’ efforts and promoting recruitment of fellows to VA positions.
VAQS has enrolled 96 fellows from 1999 to 2008; 75 have completed the program and 11 are currently enrolled. Fellowship graduates have pursued a variety of career paths: 20% are continuing training (most in VA); 32% hold a VA faculty/staff position; 63% are academic faculty; and 80% conduct clinical or research work related to health care improvement. Graduates have held leadership positions in VA, Department of Defense, and public health.
Combining knowledge about the improvement of health care with adult learning strategies, distance learning technologies, face-to-face meetings, local mentorship, and experiential projects has been successful in improving care in VA and preparing physicians to participate in, study, and lead the improvement of health care quality and safety.
doi:10.1097/ACM.0b013e3181bfdcef
PMCID: PMC3800745  PMID: 19940583
10.  Information-seeking behavior of health sciences faculty: the impact of new information technologies. 
This paper reports on an ongoing investigation into health sciences faculty's information-seeking behavior, including their use of new information technologies. A survey was administered to all faculty in medicine, nursing, and pharmacy at the University of Illinois at Chicago. It was similar to one administered to the same population in 1991. The survey asked about faculty's use of electronic resources, documented any shift from the use of print to electronic formats, and measured the utilization of library training. The response rate was 48.5% for medicine faculty, 45.0% for nursing, and 62.5% for pharmacy. The study found that use of the print Index Medicus among faculty was in transition: While 30.5% continued to use the print resources, 68.0% of faculty accessed MEDLINE through electronic means. Faculty preferred accessing electronic databases from their offices to doing so from the library. Health sciences faculty used a wide variety of databases, in addition to MEDLINE, to fill their information needs. Most faculty did not take advantage of either in-house or electronic training sessions offered by librarians. The study concluded that the training preferences of faculty need to be further explored.
PMCID: PMC226298  PMID: 9431430
11.  The ongoing evolution of the core curriculum of a clinical fellowship in pathology informatics 
The Partners HealthCare system's Clinical Fellowship in Pathology Informatics (Boston, MA, USA) faces ongoing challenges to the delivery of its core curriculum in the forms of: (1) New classes of fellows annually with new and varying educational needs and increasingly fractured, enterprise-wide commitments; (2) taxing electronic health record (EHR) and laboratory information system (LIS) implementations; and (3) increasing interest in the subspecialty at the academic medical centers (AMCs) in what is a large health care network. In response to these challenges, the fellowship has modified its existing didactic sessions and piloted both a network-wide pathology informatics lecture series and regular “learning laboratories”. Didactic sessions, which had previously included more formal discussions of the four divisions of the core curriculum: Information fundamentals, information systems, workflow and process, and governance and management, now focus on group discussions concerning the fellows’ ongoing projects, updates on the enterprise-wide EHR and LIS implementations, and directed questions about weekly readings. Lectures are given by the informatics faculty, guest informatics faculty, current and former fellows, and information systems members in the network, and are open to all professional members of the pathology departments at the AMCs. Learning laboratories consist of small-group exercises geared toward a variety of learning styles, and are driven by both the fellows and a member of the informatics faculty. The learning laboratories have created a forum for discussing real-time and real-world pathology informatics matters, and for incorporating awareness of and timely discussions about the latest pathology informatics literature. These changes have diversified the delivery of the fellowship's core curriculum, increased exposure of faculty, fellows and trainees to one another, and more equitably distributed teaching responsibilities among the entirety of the pathology informatics asset in the network. Though the above approach has been in place less than a year, we are presenting it now as a technical note to allow for further discussion of evolving educational opportunities in pathology informatics and clinical informatics in general, and to highlight the importance of having a flexible fellowship with active participation from its fellows.
doi:10.4103/2153-3539.137717
PMCID: PMC4141423  PMID: 25191621
Clinical informatics curriculum; clinical informatics teaching; pathology informatics; pathology informatics curriculum; pathology informatics teaching
12.  Developing a Culture of Research in Vermont: Training and Research Support for Faculty and Students Through Outreach 
The Vermont Genetics Network (VGN) Outreach Core works with undergraduate college faculty throughout the state to implement and integrate cutting edge technology into their curricula and research programs. The opportunities afforded to undergraduates exposed to VGN Outreach activities allow them to gain important skills and encourage them to pursue research careers. The VGN Outreach Core, based at the University of Vermont (UVM) and Norwich University, has utilized the technologies and expertise from the three VGN Core Facilities at UVM – Microarray, Proteomics, and Bioinformatics – to support faculty and student research and to create educational modules.
Through these modules, our team has worked with over 20 faculty and 560 undergraduate students from eight baccalaureate partner institutions (BPIs). Seven of the eight colleges have integrated one or more modules into their curricula and all eight BPIs have reported other changes to curricula that were influenced by VGN Outreach interactions. Results from outreach surveys suggest that our outreach programs influence the educational and career goals of undergraduates. Students report an increased interest in studying science and pursuing a career in science or medicine after participating in VGN educational modules. Further results from the outreach surveys will be discussed.
Additionally, the VGN Outreach Core directly supports faculty and student research. The team works with faculty to enhance their research by bringing research into the classroom, integrating novel experiments into the modules, establishing relationships with the core facilities, offering technical support for project design, and providing extensive bioinformatics support. Core members also work with undergraduate students by serving as technical advisors and/or thesis committee members for independent senior projects and by providing research support. Through all the VGN Programs, a stronger culture of research is being developed at our partner institutes and around the state.
This work was sponsored by Grant Number P20 RR16462, from the IDeA Network of Biomedical Research Excellence (INBRE) Program of the National Institute of General Medical Sciences (NIGMS), a component of the National Institutes of Health (NIH).
PMCID: PMC3635394
13.  Clinical and Translational Research Studios: A Multidisciplinary Internal Support Program 
Academic Medicine  2012;87(8):1052-1059.
The Vanderbilt Institute for Clinical and Translational Research implemented the “Studio” Program in 2007 to bring together experts to provide free, structured, project-specific feedback for medical researchers. Studios are a series of integrated, dynamic, and interactive roundtable discussions that bring relevant research experts from diverse academic disciplines together to focus on a specific research project at a specific stage. Vanderbilt’s Clinical and Translational Science Award supports the program, which is designed to improve the quality and impact of biomedical research. In this article, the authors describe the program’s design, and they provide an evaluation of its first four years.
After an investigator completes a brief online studio application, a studio “manager” reviews the request, assembles a panel of 3 to 6 experts (research faculty from multiple disciplines), and circulates the pre-review materials electronically. Investigators can request one of seven studio formats: hypothesis generation, study design, grant review, implementation, analysis and interpretation, manuscript review, or translation. A studio moderator leads each studio session, managing the time (90 minutes) and discussion to optimize the usefulness of the session for the investigator.
Feedback from the 157 studio sessions in the first four years has been overwhelmingly positive. Investigators have indicated that their studios have improved the quality of their science (99%; 121/122 responses), and experts have reported that the studios have been a valuable use of their time (98%; 398/406 responses). To achieve the health goals of the 21st century, researchers from multiple disciplines must bridge their differences and together address the challenging problems that face us. -- The Institute of Medicine, 20011
doi:10.1097/ACM.0b013e31825d29d4
PMCID: PMC3406254  PMID: 22722360
14.  Interprofessional collaboration: three best practice models of interprofessional education 
Medical Education Online  2011;16:10.3402/meo.v16i0.6035.
Interprofessional education is a collaborative approach to develop healthcare students as future interprofessional team members and a recommendation suggested by the Institute of Medicine. Complex medical issues can be best addressed by interprofessional teams. Training future healthcare providers to work in such teams will help facilitate this model resulting in improved healthcare outcomes for patients. In this paper, three universities, the Rosalind Franklin University of Medicine and Science, the University of Florida and the University of Washington describe their training curricula models of collaborative and interprofessional education.
The models represent a didactic program, a community-based experience and an interprofessional-simulation experience. The didactic program emphasizes interprofessional team building skills, knowledge of professions, patient centered care, service learning, the impact of culture on healthcare delivery and an interprofessional clinical component. The community-based experience demonstrates how interprofessional collaborations provide service to patients and how the environment and availability of resources impact one's health status. The interprofessional-simulation experience describes clinical team skills training in both formative and summative simulations used to develop skills in communication and leadership.
One common theme leading to a successful experience among these three interprofessional models included helping students to understand their own professional identity while gaining an understanding of other professional's roles on the health care team. Commitment from departments and colleges, diverse calendar agreements, curricular mapping, mentor and faculty training, a sense of community, adequate physical space, technology, and community relationships were all identified as critical resources for a successful program. Summary recommendations for best practices included the need for administrative support, interprofessional programmatic infrastructure, committed faculty, and the recognition of student participation as key components to success for anyone developing an IPE centered program.
doi:10.3402/meo.v16i0.6035
PMCID: PMC3081249  PMID: 21519399
interprofessional; healthcare teams; collaboration; interprofessional education; interprofessional curricula models
15.  Building Global Health Through a Center-Without-Walls: The Vanderbilt Institute for Global Health 
The Institute for Global Health at Vanderbilt enables the expansion and coordination of global health research, service, and training, reflecting the university's commitment to improve health services and outcomes in resource-limited settings. Global health encompasses both prevention via public health and treatment via medical care, all nested within a broader community-development context. This has fostered university-wide collaborations to address education, business/economics, engineering, nursing, and language training, among others. The institute is a natural facilitator for team building and has been especially helpful in organizing institutional responses to global health solicitations from the National Institutes of Health (NIH), Centers for Disease Control (CDC), and other funding agencies. This center-without-walls philosophy nurtures noncompetitive partnerships among and within departments and schools. With extramural support from the NIH and from endowment and developmental investments from the school of medicine, the institute funds new pilot projects to nurture global educational and research exchanges related to health and development. Vanderbilt's newest programs are a CDC-supported HIV/AIDS service initiative in Africa and an overseas research training program for health science graduate students and clinical fellows. New opportunities are available for Vanderbilt students, staff, and faculty to work abroad in partnership with international health projects through a number of Tennessee institutions now networked with the institute. A center-without-walls may be a model for institutions contemplating strategic investments to better organize service and teaching opportunities abroad, and to achieve greater successes in leveraging extramural support for overseas and domestic work focused on tropical medicine and global health.
doi:10.1097/ACM.0b013e318160b76c
PMCID: PMC2564795  PMID: 18303361
16.  Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx.
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.
Objective
The objective of this analysis was to conduct an evidence-based assessment of home telehealth technologies for patients with chronic obstructive pulmonary disease (COPD) in order to inform recommendations regarding the access and provision of these services in Ontario. This analysis was one of several analyses undertaken to evaluate interventions for COPD. The perspective of this assessment was that of the Ontario Ministry of Health and Long-Term Care, a provincial payer of medically necessary health care services.
Clinical Need: Condition and Target Population
Canada is facing an increase in chronic respiratory diseases due in part to its aging demographic. The projected increase in COPD will put a strain on health care payers and providers. There is therefore an increasing demand for telehealth services that improve access to health care services while maintaining or improving quality and equality of care. Many telehealth technologies however are in the early stages of development or diffusion and thus require study to define their application and potential harms or benefits. The Medical Advisory Secretariat (MAS) therefore sought to evaluate telehealth technologies for COPD.
Technology
Telemedicine (or telehealth) refers to using advanced information and communication technologies and electronic medical devices to support the delivery of clinical care, professional education, and health-related administrative services.
Generally there are 4 broad functions of home telehealth interventions for COPD:
to monitor vital signs or biological health data (e.g., oxygen saturation),
to monitor symptoms, medication, or other non-biologic endpoints (e.g., exercise adherence),
to provide information (education) and/or other support services (such as reminders to exercise or positive reinforcement), and
to establish a communication link between patient and provider.
These functions often require distinct technologies, although some devices can perform a number of these diverse functions. For the purposes of this review, MAS focused on home telemonitoring and telephone only support technologies.
Telemonitoring (or remote monitoring) refers to the use of medical devices to remotely collect a patient’s vital signs and/or other biologic health data and the transmission of those data to a monitoring station for interpretation by a health care provider.
Telephone only support refers to disease/disorder management support provided by a health care provider to a patient who is at home via telephone or videoconferencing technology in the absence of transmission of patient biologic data.
Research Questions
What is the effectiveness, cost-effectiveness, and safety of home telemonitoring compared with usual care for patients with COPD?
What is the effectiveness, cost-effectiveness, and safety of telephone only support programs compared with usual care for patients with COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on November 3, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Cochrane Library, and the International Agency for Health Technology Assessment (INAHTA) for studies published from January 1, 2000 until November 3, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with unknown eligibility were reviewed with a second clinical epidemiologist, and then a group of epidemiologists until consensus was established. The quality of evidence was assessed as high, moderate, low, or very low according to GRADE methodology.
Inclusion Criteria – Question #1
frequent transmission of a patient’s physiological data collected at home and without a health care professional physically present to health care professionals for routine monitoring through the use of a communication technology;
monitoring combined with a coordinated management and feedback system based on transmitted data;
telemonitoring as a key component of the intervention (subjective determination);
usual care as provided by the usual care provider for the control group;
randomized controlled trials (RCTs), controlled clinical trials (CCTs), systematic reviews, and/or meta-analyses;
published between January 1, 2000 and November 3, 2010.
Inclusion Criteria – Question #2
scheduled or frequent contact between patient and a health care professional via telephone or videoconferencing technology in the absence of transmission of patient physiological data;
monitoring combined with a coordinated management and feedback system based on transmitted data;
telephone support as a key component of the intervention (subjective determination);
usual care as provided by the usual care provider for the control group;
RCTs, CCTs, systematic reviews, and/or meta-analyses;
published between January 1, 2000 and November 3, 2010.
Exclusion Criteria
published in a language other than English;
intervention group (and not control) receiving some form of home visits by a medical professional, typically a nurse (i.e., telenursing) beyond initial technology set-up and education, to collect physiological data, or to somehow manage or treat the patient;
not recording patient or health system outcomes (e.g., technical reports testing accuracy, reliability or other development-related outcomes of a device, acceptability/feasibility studies, etc.);
not using an independent control group that received usual care (e.g., studies employing historical or periodic controls).
Outcomes of Interest
hospitalizations (primary outcome)
mortality
emergency department visits
length of stay
quality of life
other […]
Subgroup Analyses (a priori)
length of intervention (primary)
severity of COPD (primary)
Quality of Evidence
The quality of evidence assigned to individual studies was determined using a modified CONSORT Statement Checklist for Randomized Controlled Trials. (1) The CONSORT Statement was adapted to include 3 additional quality measures: the adequacy of control group description, significant differential loss to follow-up between groups, and greater than or equal to 30% study attrition. Individual study quality was defined based on total scores according to the CONSORT Statement checklist: very low (0 to < 40%), low (≥ 40 to < 60%), moderate (≥ 60 to < 80%), and high (≥ 80 to 100%).
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Six publications, representing 5 independent trials, met the eligibility criteria for Research Question #1. Three trials were RCTs reported across 4 publications, whereby patients were randomized to home telemonitoring or usual care, and 2 trials were CCTs, whereby patients or health care centers were nonrandomly assigned to intervention or usual care.
A total of 310 participants were studied across the 5 included trials. The mean age of study participants in the included trials ranged from 61.2 to 74.5 years for the intervention group and 61.1 to 74.5 years for the usual care group. The percentage of men ranged from 40% to 64% in the intervention group and 46% to 72% in the control group.
All 5 trials were performed in a moderate to severe COPD patient population. Three trials initiated the intervention following discharge from hospital. One trial initiated the intervention following a pulmonary rehabilitation program. The final trial initiated the intervention during management of patients at an outpatient clinic.
Four of the 5 trials included oxygen saturation (i.e., pulse oximetry) as one of the biological patient parameters being monitored. Additional parameters monitored included forced expiratory volume in one second, peak expiratory flow, and temperature.
There was considerable clinical heterogeneity between trials in study design, methods, and intervention/control. In relation to the telemonitoring intervention, 3 of the 5 included studies used an electronic health hub that performed multiple functions beyond the monitoring of biological parameters. One study used only a pulse oximeter device alone with modem capabilities. Finally, in 1 study, patients measured and then forwarded biological data to a nurse during a televideo consultation. Usual care varied considerably between studies.
Only one trial met the eligibility criteria for Research Question #2. The included trial was an RCT that randomized 60 patients to nurse telephone follow-up or usual care (no telephone follow-up). Participants were recruited from the medical department of an acute-care hospital in Hong Kong and began receiving follow-up after discharge from the hospital with a diagnosis of COPD (no severity restriction). The intervention itself consisted of only two 10-to 20-minute telephone calls, once between days 3 to 7 and once between days 14 to 20, involving a structured, individualized educational and supportive programme led by a nurse that focused on 3 components: assessment, management options, and evaluation.
Regarding Research Question #1:
Low to very low quality evidence (according to GRADE) finds non-significant effects or conflicting effects (of significant or non-significant benefit) for all outcomes examined when comparing home telemonitoring to usual care.
There is a trend towards significant increase in time free of hospitalization and use of other health care services with home telemonitoring, but these findings need to be confirmed further in randomized trials of high quality.
There is severe clinical heterogeneity between studies that limits summary conclusions.
The economic impact of home telemonitoring is uncertain and requires further study.
Home telemonitoring is largely dependent on local information technologies, infrastructure, and personnel, and thus the generalizability of external findings may be low. Jurisdictions wishing to replicate home telemonitoring interventions should likely test those interventions within their jurisdictional framework before adoption, or should focus on home-grown interventions that are subjected to appropriate evaluation and proven effective.
Regarding Research Question #2:
Low quality evidence finds significant benefit in favour of telephone-only support for self-efficacy and emergency department visits when compared to usual care, but non-significant results for hospitalizations and hospital length of stay.
There are very serious issues with the generalizability of the evidence and thus additional research is required.
PMCID: PMC3384362  PMID: 23074421
17.  Computers in Medical Education: A Cooperative Approach to Planning and Implementation 
After years of ‘ad hoc’ growth in the use of computers in the curriculum, the University of Minnesota Medical School in cooperation with the Bio-Medical Library and Health Sciences Computing Services developed and began implementation of a plan for integration of medical informatics into all phases of medical education.
Objectives were developed which focus on teaching skills related to:
1) accessing, retrieving, evaluating and managing medical information;
2) appropriate utilization of computer-assisted instruction lessons;
3) electronic communication with fellow students and medical faculty; and
4) fostering a lifelong commitment to effective use of computers to solve clinical problems.
Surveys assessed the status of computer expertise among faculty and entering students. The results of these surveys, lessons learned from this experience, and implications for the future of computers in medical education are discussed.
PMCID: PMC2245246
18.  Animating the curriculum: integrating multimedia into teaching. 
At many medical schools, the medical library assists faculty in finding and integrating new technology into the classroom, student laboratories, and lecture or small group sessions. Libraries also provide faculty with a place to do development. This paper recounts the author's experience creating software-based educational materials. In the process of creating the Slice of Life videodisc and developing and distributing other medical education software, techniques that do and do not work in producing multimedia for medical education became evident. Use of multimedia features and new modalities not possible with books, rather than development of electronic versions of texts and atlases, should be emphasized. Important human factors include collaboration, continuity, evaluation, and sharing of equipment, software, code, effort, expertise, and experiences. Distribution and technical support also are important activities in which medical libraries can participate.
PMCID: PMC225884  PMID: 8004014
19.  Interprofessional faculty development: integration of oral health into the geriatric diabetes curriculum, from theory to practice 
Background
Health care workforce shortages and an increase demand for health care services by an older demographic challenged by oral–systemic conditions are being recognized across health care systems. Demands are placed on health care professionals to render coordinated delivery of services. Management of oral–systemic conditions requires a trained health care workforce to render interprofessional patient-centered and coordinated delivery of health care services. The purpose of this investigation was to evaluate the effectiveness of an interprofessional health care faculty training program.
Methods
A statewide comprehensive type 2 diabetes training program was developed and offered to multidisciplinary health care faculty using innovative educational methods. Video-recorded clinically simulated patient encounters concentrated on the oral–systemic interactions between type 2 diabetes and comorbidities. Post-encounter instructors facilitated debriefing focused on preconceptions, self-assessment, and peer discussions, to develop a joint interprofessional care plan. Furthermore, the health care faculty explored nonhierarchical opportunities to bridge common health care themes and concepts, as well as opportunities to translate information into classroom instruction and patient care.
Results
Thirty-six health care faculty from six disciplines completed the pre-research and post-research assessment survey to evaluate attitudes, knowledge, and perceptions following the interprofessional health care faculty training program. Post-training interprofessional team building knowledge improved significantly. The health care faculty post-training attitude scores improved significantly, with heightened awareness of the unique oral–systemic care needs of older adults with type 2 diabetes, supporting an interprofessional team approach to care management. In addition, the health care faculty viewed communication across disciplines as being essential and interprofessional training as being vital to the core curriculum of each discipline. Significant improvement occurred in the perception survey items for team accountability and use of uniform terminology to bridge communication gaps.
Conclusion
Attitude, knowledge, and perceptions of health care faculty regarding interprofessional team building and the team approach to management of the oral–systemic manifestations of chronic disease in older adults was improved. Uniform language to promote communication across health professionals, care settings, and caregivers/patients, was noted. Interprofessional team building/care planning should be integrated in core curricula.
doi:10.2147/JMDH.S54851
PMCID: PMC3862736  PMID: 24363558
team building; patient-centered care; oral–systemic; older adults
20.  The Effectiveness of Mobile-Health Technologies to Improve Health Care Service Delivery Processes: A Systematic Review and Meta-Analysis 
PLoS Medicine  2013;10(1):e1001363.
Caroline Free and colleagues systematically review controlled trials of mobile technology interventions to improve health care delivery processes and show that current interventions give only modest benefits and that high-quality trials measuring clinical outcomes are needed.
Background
Mobile health interventions could have beneficial effects on health care delivery processes. We aimed to conduct a systematic review of controlled trials of mobile technology interventions to improve health care delivery processes.
Methods and Findings
We searched for all controlled trials of mobile technology based health interventions using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990–Sept 2010). Two authors independently extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and we used random effects meta-analysis to give pooled estimates.
We identified 42 trials. None of the trials had low risk of bias. Seven trials of health care provider support reported 25 outcomes regarding appropriate disease management, of which 11 showed statistically significant benefits. One trial reported a statistically significant improvement in nurse/surgeon communication using mobile phones. Two trials reported statistically significant reductions in correct diagnoses using mobile technology photos compared to gold standard. The pooled effect on appointment attendance using text message (short message service or SMS) reminders versus no reminder was increased, with a relative risk (RR) of 1.06 (95% CI 1.05–1.07, I2 = 6%). The pooled effects on the number of cancelled appointments was not significantly increased RR 1.08 (95% CI 0.89–1.30). There was no difference in attendance using SMS reminders versus other reminders (RR 0.98, 95% CI 0.94–1.02, respectively). To address the limitation of the older search, we also reviewed more recent literature.
Conclusions
The results for health care provider support interventions on diagnosis and management outcomes are generally consistent with modest benefits. Trials using mobile technology-based photos reported reductions in correct diagnoses when compared to the gold standard. SMS appointment reminders have modest benefits and may be appropriate for implementation. High quality trials measuring clinical outcomes are needed.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Over the past few decades, computing and communication technologies have changed dramatically. Bulky, slow computers have been replaced by portable devices that can complete increasingly complex tasks in less and less time. Similarly, landlines have been replaced by mobile phones and other mobile communication technologies that can connect people anytime and anywhere, and that can transmit text messages (short message service; SMS), photographs, and data at the touch of a button. These advances have led to the development of mobile-health (mHealth)—the use of mobile computing and communication technologies in health care and public health. mHealth has many applications. It can be used to facilitate data collection and to encourage health-care consumers to adopt healthy lifestyles or to self-manage chronic conditions. It can also be used to improve health-care service delivery processes by targeting health-care providers or communication between these providers and their patients. So, for example, mobile technologies can be used to provide clinical management support in settings where there are no specialist clinicians, and they can be used to send patients test results and timely reminders of appointments.
Why Was This Study Done?
Many experts believe that mHealth interventions could greatly improve health-care delivery processes, particularly in resource-poor settings. The results of several controlled trials (studies that compare the outcomes of people who do or do not receive an intervention) of mHealth interventions designed to improve health-care delivery processes have been published. However, these data have not been comprehensively reviewed, and the effectiveness of this type of mHealth intervention has not been quantified. Here, the researchers rectify this situation by undertaking a systematic review and meta-analysis of controlled trials of mobile technology-based interventions designed to improve health-care service delivery processes. A systematic review is a study that uses predefined criteria to identify all the research on a given topic; a meta-analysis is a statistical approach that is used to pool the results of several independent studies.
What Did the Researchers Do and Find?
The researchers identified 42 controlled trials that investigated mobile technology-based interventions designed to improve health-care service delivery processes. None of the trials were of high quality—many had methodological problems likely to affect the accuracy of their findings—and nearly all were undertaken in high-income countries. Thirty-two of the trials tested interventions directed at health-care providers. Of these trials, seven investigated interventions providing health-care provider education, 18 investigated interventions supporting clinical diagnosis and treatment, and seven investigated interventions to facilitate communication between health-care providers. Several of the trials reported that the tested intervention led to statistically significant improvements (improvements unlikely to have happened by chance) in outcomes related to disease management. However, two trials that used mobile phones to transmit photos to off-site clinicians for diagnosis reported significant reductions in correct diagnoses compared to diagnosis by an on-site specialist. Ten of the 42 trials investigated interventions targeting communication between health-care providers and patients. Eight of these trials investigated SMS-based appointment reminders. Meta-analyses of the results of these trials indicated that using SMS appointment reminders significantly but modestly increased patient attendance compared to no reminders. However, SMS reminders were no more effective than postal or phone call reminders, and texting reminders to patients who persistently missed appointments did not significantly change the number of cancelled appointments.
What Do These Findings Mean?
These findings indicate that some mHealth interventions designed to improve health-care service delivery processes are modestly effective, but they also highlight the need for more trials of these interventions. Specifically, these findings show that although some interventions designed to provide support for health-care providers modestly improved some aspects of clinical diagnosis and management, other interventions had deleterious effects—most notably, the use of mobile technology–based photos for diagnosis. In terms of mHealth interventions targeting communication between health-care providers and patients, the finding that SMS appointment reminders have modest benefits suggests that implementation of this intervention should be considered, at least in high-income settings. However, the researchers stress that more trials are needed to robustly establish the ability of mobile technology-based interventions to improve health-care delivery processes. These trials need to be of high quality, they should be undertaken in resource-limited settings as well as in high-income countries, and, ideally, they should consider interventions that combine mHealth and conventional approaches.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001363.
A related PLOS Medicine Research Article by Free et al. investigates the effectiveness of mHealth technology-based health behavior change and disease management interventions for health-care consumers
Wikipedia has a page on mHealth (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
mHealth: New horizons for health through mobile technologies is a global survey of mHealth prepared by the World Health Organization’s Global Observatory for eHealth (eHealth is health-care practice supported by electronic processes and communication)
The mHealth in Low-Resource Settings website, which is maintained by the Netherlands Royal Tropical Institute, provides information on the current use, potential, and limitations of mHealth in low-resource settings
The US National Institutes of Health Fogarty International Center provides links to resources and information about mHealth
doi:10.1371/journal.pmed.1001363
PMCID: PMC3566926  PMID: 23458994
21.  Evaluation of a web-based portal to improve resident education by neonatology fellows 
Medical Education Online  2014;19:10.3402/meo.v19.24403.
Background
Integration of web-based educational tools into medical training has been shown to increase accessibility of resources and optimize teaching. We developed a web-based educational portal (WBEP) to support teaching of pediatric residents about newborn medicine by neonatology fellows.
Objectives
1) To compare residents’ attitudes about their fellow-led education in the NICU pre- and post-WBEP; including assessment of factors that impact their education and usefulness of teaching tools. 2) To compare fellow utilization of various teaching modalities pre- and post-WBEP.
Design/methods
We queried residents about their attitudes regarding fellow-led education efforts and various teaching modalities in the NICU and logistics potentially impacting effectiveness. Based on these data, we introduced the WBEP – a repository of teaching tools (e.g., mock code cases, board review questions, journal articles, case-based discussion scenarios) for use by fellows to supplement didactic sessions in a faculty-based curriculum. We surveyed residents about the effectiveness of fellow teaching pre- and post-WBEP implementation and the type of fellow-led teaching modalities that were used.
Results
After analysis of survey responses, we identified that residents cited fellow level of interest as the most important factor impacting their education. Post-implementation, residents described greater utilization of various teaching modalities by fellows, including an increase in use of mock codes (14% to 76%, p<0.0001) and journal articles (33% to 59%, p=0.02).
Conclusions
A web-based resource that supplements traditional curricula led to greater utilization of various teaching modalities by fellows and may encourage fellow involvement in resident teaching.
doi:10.3402/meo.v19.24403
PMCID: PMC4110380  PMID: 25059834
WBEP; NICU; resident education; fellow-led teaching
22.  Information-seeking behavior: a survey of health sciences faculty use of indexes and databases. 
This study investigated information-seeking behavior, including use of major bibliographic tools by medical, pharmacy, nursing, and science faculty at the University of Illinois at Chicago. The study assessed the impact of availability of locally mounted databases, determined needs for modification of instructional programs, identified the need for promotional material, and established a baseline for subsequent studies. Results reflected a wide variation in the number and format of secondary services used by faculty. Over 70% of all faculty from the colleges of medicine, pharmacy, and nursing used Index Medicus or MEDLINE. There were statistically significant differences between colleges in their use of mediated and end-user searching of MEDLINE. Colleges exhibited significant differences in use of Current Contents, PsycLIT, ERIC, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Chemical Abstracts, and Science Citation Index. Statistically significant differences also were found among several clinical departments. The study concluded that, as new formats to bibliographic tools become available, traditional formats continue to be used; training sessions must be tailored to the audience; and the availability of local resources and their use by faculty needs to be understood.
PMCID: PMC225821  PMID: 8251974
23.  Engaging Actively with Issues in the Responsible Conduct of Science: Lessons from International Efforts Are Relevant for Undergraduate Education in the United States 
CBE Life Sciences Education  2013;12(4):596-603.
This Feature describes a National Research Council project centered on educating faculty in the Middle East/North Africa and Asia to use active learning when teaching responsible conduct of science (RCS). It provides insights for faculty in the United States as they engage students in the intricacies of RCS or establish “train-the-trainer” programs at their home institutions.
Numerous studies are demonstrating that engaging undergraduate students in original research can improve their achievement in the science, technology, engineering, and mathematics (STEM) fields and increase the likelihood that some of them will decide to pursue careers in these disciplines. Associated with this increased prominence of research in the undergraduate curriculum are greater expectations from funders, colleges, and universities that faculty mentors will help those students, along with their graduate students and postdoctoral fellows, develop an understanding and sense of personal and collective obligation for responsible conduct of science (RCS). This Feature describes an ongoing National Research Council (NRC) project and a recent report about educating faculty members in culturally diverse settings (Middle East/North Africa and Asia) to employ active-learning strategies to engage their students and colleagues deeply in issues related to RCS. The NRC report describes the first phase of this project, which took place in Aqaba and Amman, Jordan, in September 2012 and April 2013, respectively. Here we highlight the findings from that report and our subsequent experience with a similar interactive institute in Kuala Lumpur, Malaysia. Our work provides insights and perspectives for faculty members in the United States as they engage undergraduate and graduate students, as well as postdoctoral fellows, to help them better understand the intricacies of and connections among various components of RCS. Further, our experiences can provide insights for those who may wish to establish “train-the-trainer” programs at their home institutions.
doi:10.1187/cbe.13-09-0184
PMCID: PMC3846510  PMID: 24297287
24.  Interdisciplinary multiinstitutional alliances in support of educational programs for health sciences librarians. 
This project responds to the need to identify the knowledge, skills, and expertise required by health sciences librarians in the future and to devise mechanisms for providing this requisite training. The approach involves interdisciplinary multiinstitutional alliances with collaborators drawn from two graduate schools of library and information science (University of Illinois at Urbana-Champaign and Indiana University) and two medical schools (University of Illinois at Chicago and Washington University). The project encompasses six specific aims: (1) investigate the evolving role of the health sciences librarian; (2) analyze existing programs of study in library and information science at all levels at Illinois and Indiana; (3) develop opportunities for practicums, internships, and residencies; (4) explore the possibilities of computing and communication technologies to enhance instruction; (5) identify mechanisms to encourage faculty and graduate students to participate in medical informatics research projects; and (6) create recruitment strategies to achieve better representation of currently underrepresented groups. The project can serve as a model for other institutions interested in regional collaboration to enhance graduate education for health sciences librarianship.
PMCID: PMC226197  PMID: 8913560
25.  Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients with Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm.
For more information on the economic analysis, please visit the PATH website: http://www.path-hta.ca/About-Us/Contact-Us.aspx.
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact.
Objective
The objective of this analysis was to compare hospital-at-home care with inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) who present to the emergency department (ED).
Clinical Need: Condition and Target Population
Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The natural history of COPD involves periods of acute-onset worsening of symptoms, particularly increased breathlessness, cough, and/or sputum, that go beyond normal day-to-day variations; these are known as acute exacerbations.
Two-thirds of COPD exacerbations are caused by an infection of the tracheobronchial tree or by air pollution; the cause in the remaining cases is unknown. On average, patients with moderate to severe COPD experience 2 or 3 exacerbations each year.
Exacerbations have an important impact on patients and on the health care system. For the patient, exacerbations result in decreased quality of life, potentially permanent losses of lung function, and an increased risk of mortality. For the health care system, exacerbations of COPD are a leading cause of ED visits and hospitalizations, particularly in winter.
Technology
Hospital-at-home programs offer an alternative for patients who present to the ED with an exacerbation of COPD and require hospital admission for their treatment. Hospital-at-home programs provide patients with visits in their home by medical professionals (typically specialist nurses) who monitor the patients, alter patients’ treatment plans if needed, and in some programs, provide additional care such as pulmonary rehabilitation, patient and caregiver education, and smoking cessation counselling.
There are 2 types of hospital-at-home programs: admission avoidance and early discharge hospital-at-home. In the former, admission avoidance hospital-at-home, after patients are assessed in the ED, they are prescribed the necessary medications and additional care needed (e.g., oxygen therapy) and then sent home where they receive regular visits from a medical professional. In early discharge hospital-at-home, after being assessed in the ED, patients are admitted to the hospital where they receive the initial phase of their treatment. These patients are discharged into a hospital-at-home program before the exacerbation has resolved. In both cases, once the exacerbation has resolved, the patient is discharged from the hospital-at-home program and no longer receives visits in his/her home.
In the models that exist to date, hospital-at-home programs differ from other home care programs because they deal with higher acuity patients who require higher acuity care, and because hospitals retain the medical and legal responsibility for patients. Furthermore, patients requiring home care services may require such services for long periods of time or indefinitely, whereas patients in hospital-at-home programs require and receive the services for a short period of time only.
Hospital-at-home care is not appropriate for all patients with acute exacerbations of COPD. Ineligible patients include: those with mild exacerbations that can be managed without admission to hospital; those who require admission to hospital; and those who cannot be safely treated in a hospital-at-home program either for medical reasons and/or because of a lack of, or poor, social support at home.
The proposed possible benefits of hospital-at-home for treatment of exacerbations of COPD include: decreased utilization of health care resources by avoiding hospital admission and/or reducing length of stay in hospital; decreased costs; increased health-related quality of life for patients and caregivers when treated at home; and reduced risk of hospital-acquired infections in this susceptible patient population.
Ontario Context
No hospital-at-home programs for the treatment of acute exacerbations of COPD were identified in Ontario. Patients requiring acute care for their exacerbations are treated in hospitals.
Research Question
What is the effectiveness, cost-effectiveness, and safety of hospital-at-home care compared with inpatient hospital care of acute exacerbations of COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on August 5, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 1990, to August 5, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search.
Inclusion Criteria
English language full-text reports;
health technology assessments, systematic reviews, meta-analyses, and randomized controlled trials (RCTs);
studies performed exclusively in patients with a diagnosis of COPD or studies including patients with COPD as well as patients with other conditions, if results are reported for COPD patients separately;
studies performed in patients with acute exacerbations of COPD who present to the ED;
studies published between January 1, 1990, and August 5, 2010;
studies comparing hospital-at-home and inpatient hospital care for patients with acute exacerbations of COPD;
studies that include at least 1 of the outcomes of interest (listed below).
Cochrane Collaboration reviews have defined hospital-at-home programs as those that provide patients with active treatment for their acute exacerbation in their home by medical professionals for a limited period of time (in this case, until the resolution of the exacerbation). If a hospital-at-home program had not been available, these patients would have been admitted to hospital for their treatment.
Exclusion Criteria
< 18 years of age
animal studies
duplicate publications
grey literature
Outcomes of Interest
Patient/clinical outcomes
mortality
lung function (forced expiratory volume in 1 second)
health-related quality of life
patient or caregiver preference
patient or caregiver satisfaction with care
complications
Health system outcomes
hospital readmissions
length of stay in hospital and hospital-at-home
ED visits
transfer to long-term care
days to readmission
eligibility for hospital-at-home
Statistical Methods
When possible, results were pooled using Review Manager 5 Version 5.1; otherwise, results were summarized descriptively. Data from RCTs were analyzed using intention-to-treat protocols. In addition, a sensitivity analysis was done assigning all missing data/withdrawals to the event. P values less than 0.05 were considered significant. A priori subgroup analyses were planned for the acuity of hospital-at-home program, type of hospital-at-home program (early discharge or admission avoidance), and severity of the patients’ COPD. Additional subgroup analyses were conducted as needed based on the identified literature. Post hoc sample size calculations were performed using STATA 10.1.
Quality of Evidence
The quality of each included study was assessed, taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Fourteen studies met the inclusion criteria and were included in this review: 1 health technology assessment, 5 systematic reviews, and 7 RCTs.
The following conclusions are based on low to very low quality of evidence. The reviewed evidence was based on RCTs that were inadequately powered to observe differences between hospital-at-home and inpatient hospital care for most outcomes, so there is a strong possibility of type II error. Given the low to very low quality of evidence, these conclusions must be considered with caution.
Approximately 21% to 37% of patients with acute exacerbations of COPD who present to the ED may be eligible for hospital-at-home care.
Of the patients who are eligible for care, some may refuse to participate in hospital-at-home care.
Eligibility for hospital-at-home care may be increased depending on the design of the hospital-at-home program, such as the size of the geographical service area for hospital-at-home and the hours of operation for patient assessment and entry into hospital-at-home.
Hospital-at-home care for acute exacerbations of COPD was associated with a nonsignificant reduction in the risk of mortality and hospital readmissions compared with inpatient hospital care during 2- to 6-month follow-up.
Limited, very low quality evidence suggests that hospital readmissions are delayed in patients who received hospital-at-home care compared with those who received inpatient hospital care (mean additional days before readmission comparing hospital-at-home to inpatient hospital care ranged from 4 to 38 days).
There is insufficient evidence to determine whether hospital-at-home care, compared with inpatient hospital care, is associated with improved lung function.
The majority of studies did not find significant differences between hospital-at-home and inpatient hospital care for a variety of health-related quality of life measures at follow-up. However, follow-up may have been too late to observe an impact of hospital-at-home care on quality of life.
A conclusion about the impact of hospital-at-home care on length of stay for the initial exacerbation (defined as days in hospital or days in hospital plus hospital-at-home care for inpatient hospital and hospital-at-home, respectively) could not be determined because of limited and inconsistent evidence.
Patient and caregiver satisfaction with care is high for both hospital-at-home and inpatient hospital care.
PMCID: PMC3384361  PMID: 23074420

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