BACKGROUND & AIMS: BACKGROUND:National surveillance systems depend on accurate and reproducible diagnosis of infections. AIM:To investigate the effect of accuracy of diagnosing healthcare-associated infections (HCAIs) on HCAI rates in a national healthcare-associated surveillance system. METHODS:Data from the validation process from the intensive care unit (ICU) surveillance component of the German Krankenhaus Infektions Surveillance System (KISS; Hospital Infection Surveillance System) were used to calculate the accuracy of diagnosing HCAI for each individual surveillance person (SP) responsible for surveillance of HCAI in the ICU of his or her hospital. Multivariate analyses were performed to identify factors that were attributed to surveillance accuracy. FINDINGS:A total of 189 SPs responsible for surveillance in 218 ICUs assessed 30 case vignettes. The chance of belonging to the group of SPs with high accuracy was increased by being a physician (odds ratio: 3.14; P = 0.02) and by being an external SP (odds ratio: 4.69; P ≤ 0.01). ICU HCAI rates depend on the sensitivity of the ICU's SP [incidence rate ratio (IRR): 1.28 (1.07, 1.53); P ≤ 0.01]. High sensitivity increases healthcare-associated urinary tract infection rates [IRR: 1.33 (1.02, 1.75); P = 0.03] and bloodstream infection rates [IRR: 1.33 (1.06, 1.68); P = 0.01]. High specificity was not a significant factor. CONCLUSION:In light of the link between sensitivity of diagnosing HCAI by case vignettes and the ICU HCAI rates, this validation method can be recommended for validation of other surveillance systems.

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BACKGROUND & AIMS: BACKGROUND:Clinical vignettes have been used widely to compare quality of clinical care and to assess variation in practice, but the effect of different response formats has not been extensively evaluated. Our objective was to compare three clinical vignette-based survey response formats - open-ended questionnaire (A), closed-ended (multiple-choice) questionnaire with deceptive response items mixed with correct items (B), and closed-ended questionnaire with only correct items (C) - in rheumatologists' pre-treatment assessment for tumor-necrosis-factor (TNF) blocker therapy. METHODS: STUDY DESIGN:Prospective randomized study. SETTING:Rheumatologists attending the 2004 French Society of Rheumatology meeting. Physicians were given a vignette describing the history of a fictitious woman with active rheumatoid arthritis, who was a candidate for therapy with TNF blocking agents, and then were randomized to receive questionnaire A, B, or C, each containing the same four questions but with different response formats, that asked about their pretreatment assessment. MEASUREMENTS:Long (recommended items) and short (mandatory items) checklists were developed for pretreatment assessment for TNF-blocker therapy, and scores were expressed on the basis of responses to questionnaires A, B, and C as the percentage of respondents correctly choosing explicit items on these checklists. STATISTICAL ANALYSIS:Comparison of the selected items using pairwise Chi-square tests with Bonferonni correction for variables with statistically significant differences. RESULTS:Data for all surveys distributed (114 As, 118 Bs, and 118 Cs) were complete and available for analysis. The percentage of questionnaire A, B, and C respondents for whom data was correctly complete for the short checklist was 50.4%, 84.0% and 95.0%, respectively, and was 0%, 5.0% and 5.9%, respectively, for the long version. As an example, 65.8%, 85.7% and 95.8% of the respondents of A, B, and C questionnaires, respectively, correctly identified the need for tuberculin skin test (p < 0.0001). CONCLUSION:In evaluating clinical practice with use of a clinical vignette, a multiple-choice format rather than an open-ended format overestimates physician performance. The insertion of deceptive response items mixed with correct items in closed-ended (multiple-choice) questionnaire failed to avoid this overestimation.

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BACKGROUND & AIMS: BACKGROUND:Clinical vignettes are often used to elicit information about health conditions in research studies. This review summarizes the components of clinical vignettes describing Alzheimer's disease (AD) or other dementias. The purpose is to provide recommendations for the development of standardized vignettes that may be used in future studies. METHODS:MEDLINE, EMBASE, PsycINFO, ASSIA, CINAHL were searched from their inception to June 2014. Primary English-language studies employing vignettes to describe AD or similar disorders (including other dementias and Parkinson's disease) were included in the review. Included studies had to describe the content of the vignettes in the published manuscripts. The characteristics of the included studies and the vignettes were extracted in tabular form and summarized qualitatively. RESULTS:Forty-two studies were included in the review. Twenty-four of the studies contained at least one AD vignette, 11 had vignettes focusing on non-AD dementias, and seven contained vignettes describing conditions other than dementia. In total, 58 vignettes were obtained from the 42 included studies. CONCLUSIONS:Key aspects to consider when constructing vignettes for AD or other dementias include writing the vignettes from a third-person perspective and presenting hypothetical patients as being at least 65 years of age. Researchers should develop standardized vignettes for use across studies.

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BACKGROUND & AIMS: AIMS AND OBJECTIVES:To explore hospitalised heart failure (HF) patients' self-care decisions. BACKGROUND:Heart failure self-care is integral to maintain and manage health, and may prevent unnecessary HF hospitalisations. Nevertheless, self-care remains challenging for patients, and using vignettes offer a new perspective to understand patient HF self-care decision-making. DESIGN:This qualitative descriptive analysis was conducted as part of a mixed methods study. METHODS:We conducted semi-structured interviews (N = 20) to elicit patient decisions about self-care in responses to three vignettes, which varied in symptom severity. Content analysis was used to extract quotes describing participant responses. RESULTS:Participants were on average 60 years old, primarily male, African American, unemployed and highly symptomatic (NYHA Class III or IV). Overall, participants were able to identify when symptoms required a decision to seek urgent medical attention, but had difficulty identifying the appropriate decision to make in response to less acute symptoms such as swelling. CONCLUSIONS:Symptoms other than shortness of breath were challenging for patients to interpret and manage appropriately. Understanding how to apply HF knowledge to alleviate symptoms was also difficult. RELEVANCE TO CLINICAL PRACTICE:Vignettes may be a helpful tool to prompt patient-healthcare provider communication about self-care management and prompt discussions about appropriate self-care decisions in response to varying levels of symptom severity.

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BACKGROUND & AIMS: UNLABELLED:The diagnosis and management of osteoporosis have become increasingly more complex as new drugs enter the marketplace and meta-analyses of randomized trials with "other" agents become more prolific. We describe five common clinical scenarios encountered in the practice of osteoporosis medicine and various road maps that could lead to successful therapy. INTRODUCTION:The diagnosis and treatment of osteoporosis have changed dramatically in the last decade. Advances in diagnostic technologies and a range of newer treatment options have provided the clinician with a wide array of choices for treating this chronic disease. Despite the issuance of several "guidelines" and practice recommendations, there still remains confusion among clinicians about basic approaches to the management of osteoporosis. This paper should be used as a case-based approach to define optimal therapeutic choices. MATERIALS AND METHODS:Five representative cases were selected from two very large clinical practices (Bangor, ME; Pittsburgh, PA). Diagnostic modalities and treatment options used in these cases were selected on an evidence-based analysis of respective clinical trials. Subsequent to narrative choices by two metabolic bone disease specialists (SG and CR), calculation of future fracture risk and selection of potential alternative therapeutic regimens were reviewed and critiqued by an epidemiologist (DB). RESULTS:A narrative about each case and possible management choices for each of the five cases are presented with references to justify selection of the various therapeutic options. Alternatives are considered and discussed based on literature and references through July 2003. The disposition of the individual patient is noted at the end of each case. CONCLUSIONS:A case-based approach to the management of osteoporosis provides a useful interface between guidelines, evidence-based meta-analyses, and clinical practice dilemmas.

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BACKGROUND & AIMS: BACKGROUND:Valid estimates of health-related quality-of-life (HRQoL) are often difficult to obtain from persons with Alzheimer's disease (AD) and family caregiver proxies. To help assess whether the general public can serve as an alternate source of proxy HRQoL estimates in AD, we examined whether the general public can use vignettes to discriminate between AD health states. METHODS:We administered a telephone survey to randomly recruited participants from the general public who were aged 18 years or older. Interviewers read vignettes describing the mild, moderate, and severe AD health states to the participants, who answered the EQ-5D-5L and Quality of Life-Alzheimer's Disease (QoL-AD) scales as if they had AD based on the vignette descriptions. Participants also answered the EQ-5D-5L for their current health states. We converted EQ-5D-5L responses into health utility scores using Canadian preference weights. We employed the Wilcoxon signed rank test to examine whether mean health utility scores and mean QoL-AD scores differed between health states. We used Pearson's r to assess correlations between health utility and QoL-AD scores. RESULTS:Forty-eight participants (median age = 53 years; 25 female) completed the telephone interview; health utility and QoL-AD scores decreased as AD severity increased (p <0.0001). Mean health utility scores were 0.65 (mild), 0.51 (moderate), and 0.25 (severe). Mean QoL-AD scores were 26.7 (mild), 23.0 (moderate), and 17.4 (severe). The correlations between health utility and QoL-AD scores were moderate to strong (r ≥ 0.62). CONCLUSIONS:Using the vignettes, the general public provided HRQoL estimates that discriminated between the three AD health states. This finding suggests the general public may be a promising source of proxy HRQoL estimates in place of persons with AD.

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BACKGROUND & AIMS: -2

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BACKGROUND & AIMS: The use of vignettes in research and education is well documented. Documentation of how vignettes are developed and content validity is established, however, are rare. The purpose of this paper is to describe a method for development and establishing content validity of vignettes that can be used to assess student performance and research participant outcomes. This three-phase method was designed to validate seven vignettes for a future research project. Content validity index survey and expert panel interviews were used to inform improvements in validity. Findings showed that clinical vignettes were improved with respect to content relevance (from 0.93 to 0.96) and importance (from 0.68 to 0.93). Developing validated vignettes is essential when used to measure outcomes in education and in research. This three-phase method of vignette development and validation is feasible and effective in improving content validity of vignettes and can be used in other education and research projects.

背景与目标： 小插曲在研究和教育中的使用已得到充分记录。但是，很少有有关如何开发小插曲和确定内容有效性的文档。本文的目的是描述一种开发和建立小插曲内容有效性的方法，该方法可用于评估学生的表现和研究参与者的成果。此三相方法旨在验证未来研究项目的七个小插曲。内容有效性指数调查和专家小组访谈被用来告知有效性的改进。研究结果表明，在内容相关性 (从0.93到0.96) 和重要性 (从0.68到0.93) 方面，临床小插曲得到了改善。当用于衡量教育和研究成果时，开发经过验证的小插曲至关重要。这种分为三个阶段的vignette开发和验证方法在提高vignette的内容有效性方面是可行且有效的，可用于其他教育和研究项目。

BACKGROUND & AIMS: :During the longitudinal study of three patients, referred to services at 3, 13, 15 years for eating disorders, reduced food intake and anorexia nervosa, other symptoms appeared depending on difficult development, relational and personality problems. The patients showed the interweaving of symptoms at different times: they were dealing with modified developmental needs and contexts, included new possibilities of attachment that might produce different internal organizations. These changes required different treatments. Anorexia started early in life for these girls, but presented different steps of organization. We wanted to start finding some aspects of a staging model to map the course of ED, because many patients arrived later in life, reported untreated early symptoms, actually personality traits. Mapping the evolution, could allow to take care of patients at the very early stage of problems when few symptoms are present, and better patients' evolution might be possible. LEVEL OF EVIDENCE:Level V opinions of respected authorities based on clinical experience.

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BACKGROUND & AIMS: :To determine whether nurses operationally define child maltreatment in a like manner regardless of their practice specialty, eight practice groups (N = 596) participated in a mail survey. The survey allowed nurses to judge the potential seriousness of child maltreatment incidents. Multivariate statistical analyses revealed significant group differences. Follow-up analyses of variance (ANOVAs) revealed a difference between anesthetists and community health nurses on one factor (parental sexual mores). However, an investigator-developed scale demonstrated the differences would lack substantive value in clinical practice. It was concluded that nursing specialty groups define similarly the seriousness of child abuse and neglect despite varied backgrounds.

背景与目标： : 为了确定护士是否以类似的方式在操作上定义了虐待儿童的行为，无论其执业专业如何，八个执业小组 (N = 596) 参加了邮件调查。调查允许护士判断虐待儿童事件的潜在严重性。多变量统计分析显示组间存在显著差异。方差 (ANOVAs) 的后续分析显示，麻醉师和社区卫生护士在一个因素 (父母性行为) 上存在差异。然而，研究者制定的量表表明，这些差异在临床实践中缺乏实质性价值。结论是，尽管背景不同，护理专业小组对虐待儿童和忽视儿童的严重性也有类似的定义。

BACKGROUND & AIMS: -2

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BACKGROUND & AIMS: OBJECTIVES:To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities. DESIGN:Cross-sectional Health Facility Assessment linked to population-based surveillance data. SETTING:7 districts in Brong Ahafo region, Ghana. PARTICIPANTS:Most experienced delivery care providers in all 64 delivery facilities in the 7 districts. PRIMARY OUTCOME MEASURES:Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant. RESULTS:Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers (p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores. CONCLUSIONS:Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care. TRIAL REGISTRATION NUMBER:NCT00623337.

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BACKGROUND & AIMS: BACKGROUND:Physicians often select clinical management strategies not strongly supported by evidence or guidelines. Our objective was to examine the likelihood of selecting, and rationale for pursuing, clinical management strategies with more or less guideline support among physicians using clinical vignettes of eight common medical admissions. METHODS:We conducted a cross-sectional survey using clinical vignettes of attending physicians and housestaff at one internal medicine program in New York City. Each clinical vignette included a brief clinical scenario and a varying number of clinical management strategies: diagnostic tests, consultations, and treatments, some of which had strong evidence or guideline support (Level 1 strategies) while others had limited evidence or guideline support (Level 3 strategies). Likelihood of selecting a given management strategy was assessed using Likert scales and multiple response options were used to indicate rationale(s) for selections. RESULTS:Our sample included 79 physicians; 68 (86%) were younger than 40 years of age, 34 (43%) were female. There were 31 attending physicians (39%) and 48 housestaff (61%) and 39 (49%) had or planned to have primarily primary care internal medicine clinical responsibilities. Overall, physicians were more likely to select Level 1 strategies "always" or "most of the time" when compared with Level 3 strategies (82% vs. 43%; p < 0.001), with wide variation across the eight medical admissions. There were no differences between attending and housestaff physician likelihood of selecting Level 3 strategies (47% vs. 45%, p = 0.36). Supportive evidence and local practice patterns were the two most common rationales behind selections; supportive evidence was cited as the most common rationale for selecting Level 1 when compared with Level 3 strategies (63% versus 30%; p < 0.001), whereas ruling out other severe conditions was cited most often for Level 3 strategies. CONCLUSIONS:For eight common medical admissions, physicians selected more than 80% of management strategies with strong evidence or guideline support, but also selected more than 40% of strategies for which there was limited evidence or guideline support. The promotion of evidence-based care, including the avoidance of care that is not strongly supported by evidence or guidelines, may require better evidence dissemination and educational outreach to physicians.

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BACKGROUND & AIMS: OBJECTIVES:Emotional and psychological well-being are essential to overall health, but there is little research showing how to approach emotional and psychological concerns in the audiological setting. This study investigated audiologists' self-reported clinical behaviors in response to emotional and psychological concerns and/or symptoms raised by audiology clients.

DESIGN:A sample of 83 Australia-based audiologists completed a survey including vignettes presenting older adults with hearing loss and experiencing symptoms consistent with either depression or grief. Content analysis was used to explore: (1) audiologists' self-reported usual response when clients present with emotional and psychological concerns and/or symptoms in the audiological setting; (2) audiologists' ability to identify and describe psychological symptoms; and (3) audiologists' self-reported clinical behaviors relating to client referral for psychological support.

RESULTS:When asked to describe their usual clinical course of action in response to the vignettes, over one half the audiologists described actions that address the clients concerns related to psychological well-being. Where audiologists described how they would provide psychological support, they described modifications to the audiological rehabilitation program including involving significant others in the rehabilitation process, recommending additional support outside of the audiology setting (such as General Practitioner or psychologists), and providing emotional support and counseling. When prompted, the majority of participants recognized the two cases with depression as having a mental health condition; however, 48% of participants indicated the control case as also having a mental health condition. When asked directly, the majority of audiologists indicated that they would refer the three vignettes for specialist support; however, less than one third described referral to a General Practitioner and less than 5% described referral to a mental health professional as their normal course of action in the open response item. Twenty-five different professions/people were reported as potential sources for referral.

CONCLUSION:These findings support the need for further training and/or resources for audiologists to enable them to appropriately detect, describe and refer for emotional and psychological concerns and/or symptoms raised by clients' in the audiology setting.

背景与目标： 目标 : 情绪和心理健康对整体健康至关重要，但很少有研究表明如何在听力学环境中解决情绪和心理问题。这项研究调查了听力学家针对听力学客户提出的情绪和心理问题和/或症状的自我报告的临床行为。
设计 : 来自澳大利亚的83名听力学家的样本完成了一项调查，其中包括小插曲，这些小插曲显示了老年人的听力损失，并经历了与抑郁或悲伤相符的症状。内容分析用于探索 :( 1) 当客户在听力学环境中出现情绪和心理问题和/或症状时，听力学家自我报告的通常反应; (2) 听力学家识别和描述心理症状的能力; (3) 听诊者自我报告的与客户转诊有关的临床行为，以寻求心理支持。
结果 : 当被要求描述他们对小插曲的通常临床行动过程时，超过一半的听力学家描述了解决客户与心理健康有关的担忧的行动。在听力学家描述了如何提供心理支持的情况下，他们描述了对听力康复计划的修改，包括在康复过程中让重要的其他人参与进来，建议在听力学环境之外提供额外的支持 (例如全科医生或心理学家)，并提供情感支持和咨询。当提示时，大多数参与者认为这两个患有抑郁症的病例具有精神卫生状况; 然而，有48% 的参与者表示对照病例也具有精神卫生状况。当直接询问时，大多数听力学家表示，他们将把这三个小插曲转介给专家支持; 但是，在开放响应项目中，少于3分之1个描述转介给全科医生，少于5% 个描述转介给精神卫生专业人员。据报道，有25个不同的专业/人员是推荐的潜在来源。
结论 : 这些发现支持对听力学家进行进一步培训和/或资源的需求，以使他们能够适当地检测，描述并参考客户在听力学环境中提出的情绪和心理问题和/或症状。

BACKGROUND & AIMS: OBJECTIVES:To investigate the determinants of healthcare-seeking behaviour using five context-relevant clinical vignettes. The analysis deals with three issues: whether and where to seek modern care and when to seek care. SETTING:This study is set in 96 villages located in four main regions of Ethiopia. The participants of this study are 1632 rural households comprising 9455 individuals. PRIMARY AND SECONDARY OUTCOME MEASURES:Probability of seeking modern care for symptoms related to acute respiratory infections/pneumonia, diarrhoea, malaria, tetanus and tuberculosis. Conditional on choosing modern healthcare, where to seek care (health post, health centre, clinic and hospital). Conditional on choosing modern healthcare, when to seek care (seek care immediately, the next day, after 2 days, between 3 days to 1 week, a week or more). RESULTS:We find almost universal preference for modern care. Foregone care ranges from 0.6% for diarrhoea to 2.5% for tetanus. There is a systematic relationship between socioeconomic status and choice of providers mainly for adult-related conditions with households in higher consumption quintiles more likely to seek care in health centres, private/Non-Government Organization (NGO) clinics as opposed to health posts. Delays in care-seeking behaviour are apparent mainly for adult-related conditions and among poorer households. CONCLUSIONS:The analysis suggests that the lack of healthcare utilisation is not driven by the inability to recognise health problems or due to a low perceived need for modern care.

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