Monday, July 29, 2013

3 New From Biomed Central

Coulter ID, Herman PH, Nataraj S. Economic analysis of complementary, alternative, and integrative medicine: considerations raised by an expert panel. BMC Compl Alternative Med 2013, 13:191 doi:10.1186/1472-6882-13-191

Background: An international panel of experts was convened to examine the challenges faced in conducting economic analyses of Complementary, Alternative and Integrative Medicine (CAIM).
Methods: A one and a half-day panel of experts was convened in early 2011 to discuss what was needed to bring about robust economic analysis of CAIM. The goals of the expert panel were to review the current state of the science of economic evaluations in health, and to discuss the issues involved in applying these methods to CAIM, recognizing its unique characteristics. The panel proceedings were audiotaped and a thematic analysis was conducted independently by two researchers. The results were then discussed and differences resolved. This manuscript summarizes the discussions held by the panel members on each theme.
Results: The panel identified seven major themes regarding economic evaluation that are particularly salient to determining the economics of CAIM: standardization (in order to compare CAIM with conventional therapies, the same basic economic evaluation methods and framework must be used); identifying the question being asked, the audience targeted for the results and whose perspective is being used (e.g., the patient perspective is especially relevant to CAIM because of the high level of self-referral and out-of-pocket payment); the analytic methods to be used (e.g., the importance of treatment description and fidelity); the outcomes to be measured (e.g., it is important to consider a broad range of outcomes, particularly for CAIM therapies, which often treat the whole person rather than a specific symptom or disease); costs (e.g., again because of treating the whole person, the impact of CAIM on overall healthcare costs, rather than only disease-specific costs, should be measured); implementation (e.g., highlighting studies where CAIM allows cost savings may help offset its image as an "add on" cost); and generalizability (e.g., proper reporting can enable study results to be useful beyond the study sample).
Conclusions: The business case for CAIM depends on economic analysis and standard methods for conducting such economic evaluations exist. The challenge for CAIM lies in appropriately applying these methods. The deliberations of this panel provide a list of factors to be considered in meeting that challenge.

Agich G. Education and the improvement of clinical ethics services. BMC Med Educ 2013, 13:41 doi:10.1186/1472-6920-13-41
The proliferation of clinical ethics in health care institutions around the world has raised the question about the qualifications of those who serve on ethics committees and ethics consultation services. This paper discusses some of weaknesses associated with the most common educational responses to this concern and proposes a complementary approach. Since the majority of those involved in clinical ethics are practicing health professionals, the question of qualification is especially challenging as the role of ethics committees and, increasingly, ethics consultation services are becoming increasingly important to the functioning of health care institutions. Since the challenging nature of health care finances often leads institutions to rely on voluntary participation of committed health professional with only token administrative or clerical support to provide the needed ethics services, significant challenges are created for attaining competence and functional effectiveness. The article suggests that a complementary approach should be adopted for sustaining and building capacity in clinical ethics. Ethics committees and consultation services should systematically adopt quality improvement techniques to effect designed changes in clinical ethics performance and to build ethical capacity within targeted clinical units and services. Demonstrating improvements in functioning can go a long way to build confidence and capacity for clinical ethics and can help in justifying the need for support. To do so, however, requires that ethics committees and consultation services first shift attention to those areas that demonstrate weak or questionable ethical performance, including the established practices of the ethics committee and consultation service, and second seek collaboration with the involved health care providers to pursue demonstrable change. Such an approach has a much better chance of improving the capacity for clinical ethics in health care institutions than relying on educational approaches alone.
Nishimura A, Carey J, Erwin PJ, Tilburt JC, Murad MH, McCormick J. Improving understanding in the research informed consent process:a systematic review of 54 interventions tested in randomized control trials. BMC Med Ethics 2013, 14:28 doi:10.1186/1472-6939-14-28
Background: Obtaining informed consent is a cornerstone of biomedical research, yet participants comprehension of presented information is often low. The most effective interventions to improve understanding rates have not been identified.
Background: To systematically analyze the random controlled trials testing interventions to research informed consent process. The primary outcome of interest was quantitative rates of participant understanding; secondary outcomes were rates of information retention, satisfaction, and accrual. Interventional categories included multimedia, enhanced consent documents, extended discussions, test/feedback quizzes, and miscellaneous methods.
Methods: The search spanned from database inception through September 2010. It was run on Ovid MEDLINE, Ovid EMBASE, Ovid CINAHL, Ovid PsycInfo and Cochrane CENTRAL, ISI Web of Science and Scopus.Five reviewers working independently and in duplicate screened full abstract text to determine eligibility. We included only RCTs.39 out of 1523 articles fulfilled review criteria (2.6%), with a total of 54 interventions.A data extraction form was created in Distiller, an online reference management system, through an iterative process.One author collected data on study design, population, demographics, intervention, and analytical technique.
Results: Meta-analysis was possible on 22 interventions: multimedia, enhanced form, and extended discussion categories; all 54 interventions were assessed by review. Meta-analysis of multimedia approaches was associated with a non-significant increase in understanding scores (SMD 0.30, 95% CI, -0.23 to 0.84); enhanced consent form, with significant increase (SMD 1.73, 95% CI, 0.99 to 2.47); and extended discussion, with significant increase (SMD 0.53, 95% CI, 0.21 to 0.84).By review, 31% of multimedia interventions showed significant improvement in understanding; 41% for enhanced consent form; 50% for extended discussion; 33% for test/feedback; and 29% for miscellaneous.Multiple sources of variation existed between included studies: control processes, the presence of a human proctor, real vs. simulated protocol, and assessment formats.
Conclusions: Enhanced consent forms and extended discussions were most effective in improving participant understanding. Multimedia interventions, for all interventions, it is clear that they are of no threat to participant satisfaction levels or rates of accrual into studies.


Friday, July 19, 2013


Dear Colleagues: There is no new blog post for this week, as I am now off on my annual involvement in RAGBRAI. This year the route takes us from Council Bluffs on the west side of Iowa to Fort Madison on the east. The total distance this year is a brief 404 miles in total. It stops overnight at Harlan, Perry, Des Moines, Knoxville, Oskaloosa, and Fairfield.  One interesting piece of information is that the stop in Des Moines will have all riders staying at a single location- that’s 15,000 riders all in one area together.

I am hoping the heat will not be as bad this year as it was last year, when daily highs were over 100 degrees and the day we stopped in Marshalltown it hit 108. Right now, the long-range forecast looks to have highs in the mid-80s; I hope this is the case.
This column will be back Monday, July 29, once I return. I hope to have accrued a good number of points for the Health Challenge as well. :-)

Monday, July 15, 2013


I have been thinking about teaching and how much we give when get involved with our students. And because I can, I wanted to post this blog post written by oneo of my sons for his runners. My son is a teacher at Hinsdale Central High School in Hinsdale, IL as we all an assistant cross-country and track coach. These are the words he wrote just before he left for a week-long educational program in Colorado, part of his own continuing education. His blog is at

July 8, 2013-Colorado bound
Early tomorrow morning I will be leaving the Midwest for the more mountainous lands of Colorado. I will be spending 8 days in Boulder, on the campus of Colorado University, to take a class about Japan in the 21st century. I teach an East Asian Studies class here at Hinsdale Central, so participating in this course will allow me to learn the most current scholarship and to interact with some of the brightest high school educators and College professors who specialize in this content area. As an added bonus, I will get to spend time in one of the best running communities in the country. The men and women’s Cross Country teams at Colorado University are perennially challenging for the national title, and Boulder is (or was at one point) also the training grounds for many elite professional runners, including Olympic Gold Medal winner Frank Shorter as well as more recent Olympians including Adam Goucher, Jorge Torres, and Dathan Ritzenheim.

I approach this upcoming trip with a mixture of excitement and guilt. I am, of course, thrilled to be headed to a city that is one of the most beautiful I have ever seen and eager to immerse myself in the study of a topic I find fascinating. Yet, I feel that I am in some ways letting the boys of Hinsdale Central down, as I will not be there to join them in the pain of tackling tomorrows 24*400 workout, or to share in the joy of finishing it. Furthermore, I feel I am in some ways violating my own moral code by not practicing what I preach: as a Coach, I expect my athletes to commit completely to our training and to each other, and I feel apprehensive every time an athlete misses practice due to vacation or other commitment, as I understand the reality that it is much more challenging to manage the rigors of our workouts alone than it is to do so with a group.

I offer as my excuse that I think it important that I continue to grow as an educator. Every summer, I try to find professional development opportunities that enrich my life and help me become a better teacher. I’ve been fortunate over the past years to join fellow teachers for programs in Japan, China, Korea, and South Africa; to learn about the Constitution in Washington D.C.; and about African American History in both Boston and Chicago. On these programs, I’ve never wavered from my commitment to my training, and have run laps around the Imperial Palace in Japan, through the crowded streets of Shanghai and the remote rural villages of Lesotho. I find running is my favored method of learning the lay of the land in the new places I’ve visited, and on these runs the harriers of Hinsdale are never far from my mind.

In the end, I cannot satisfactorily resolve the conundrum. We remind our athletes that, ultimately, they must choose how much they are willing to commit to their own and our team’s improvement. To absent oneself from practice on a regular basis, even with the good intentions of following the training plan one one’s own, is to choose to be just a little bit less prepared than you might have been had you attended practice consistently. I am making a choice that benefits myself at the expense of our team. I’ve tried to minimize the cost by planning my travels to intersect, as much as possible, with the days that the boys will be at the Wisconsin Camp of Champions. Nonetheless, these next four days will be the one time this season when I am not in attendance.

For our team to be successful this season, however, we must have trust. As we’ve discussed all along, the character of the team will be revealed based on how practices operate in the absence of coaches. I know I can have a bit more piece of mind leaving the team with a senior class led by individuals who are unified in their goals and committed to achieving them. I do (my students) to set a high standard which our younger guys will follow.

So let’s take stock of where we are at this halfway point of the 6-week summer running program. To gain a better historical perspective, I looked back to a previous blog entry in which I compared the 2012 team’s summer training to the 2011 team. Collating three year’s together, here is how our weekly mileage for the previous two weeks compares to both those squads:

(I removed the student names here)

Given this small sample, the 2013 team compares fairly well, with 12 of the top 20 mileage runners, compared with 6 for the class of 2012 and 2 of the class of 2011. However, we know that mileage is only one part of the equation – it does not tell us about the quality of the mileage, the personalities and attitudes of the athletes, or who the eventual members of the top 7 will be [(One top runner) had run 92 miles during this period last year; (another) was suffering from some influenza-like disease and not running at all.] I interpret this data as suggesting that we are further along than previous teams but not where I believe we should be. We have 5 athletes currently above pace to make the 1000 mile club, with 5 others who are not very far off pace. Our goal is to have 15 athletes achieve this mark, and we are clearly far away from achieving this. Far too many of our team members have left for vacations and seen their mileage fall dramatically. There are some talented members of our team who are not on the list above – they’ll need to start running more consistent high mileage if we are to develop the type of supporting cast necessary to contend against the top teams in our state.

Here is how I signed off the blog post I wrote of August 7, 2012 – these are words that apply as appropriately now as they did then: In short, we should be proud of what we have accomplished so far, while at the same time recognizing that the hardest work is yet to do. The true challenge of this sport is not any single tough workout but the daily grind - doing it day in and day out, week after week, season after season in the unceasing quest for excellence.

For those of you attending the Wisconsin Camp of Champions, I hope you have fun and learn a lot. I will see you all July 22nd, fit from training at altitude, and so excited to be rejoining you in our shared journey.



Monday, July 8, 2013

Apps for the iPad

Here are some interesting apps I found recently for the iPad. I know that many of you do not have an iPad, so I will also look to find apps for Windows-based tablets as well in the near future.

Mindnode: this app costs $9.99 and is basically a concept-mapping instrument. It is intuitive to use, organizes your concept ideas neatly, and allows you to input information as well.
Shutterstock: this is a free app that is a stock image service, with the benefit of allowing you to store photos and other images around whatever topic you may be interested in.
2 Days: this app runs only $.99, and is nothing more than a to-do list that only lets you look at the current day and the next day, thus providing you information on your immediate needs and activities.
Timeli: this free all allows you to look at your timelines of projects and activities and see where and how they might overlap. It helps you to prioritize what you are doing.
Meeting-Recorder: a $1.99 app that lets you create voice memos that can be stamped and to which you can add test, or photos. Pixelmator: this is a $14.99 app that is used for image editing, so that you can retouch or clean up photographs, and then store them in the cloud.
Status Board: a $9.99 app that attempts to make your iPad look more like the dashboard on the standard Mac. It allows you to add widgets and it then gives you a one-stop shop of objects from which you can choose.
Radium 3: this app runs $9.99 and is bought via the iTunes store. It is a radio station player that allows you to customize what you hear and what you see while you play it.
Breaking News: free, this is an aggregator of, well, breaking news, from around the world. Good way to keep up on what is happening across the globe.

Vlingo: free. If you do not have Siri, this is a voice controller for an iPad or iPhone.