Recent studies show that during study abroad experiences, college students greatly increase their drinking behavior, experience multiple alcohol-related consequences, engage in sexual risk behaviors, ...and are at-risk for sexual violence victimization. These studies, however, have been limited by small sample sizes of students from single institutions who are often studying in a particular country or region. To better understand the extent of the risks experienced by college students studying abroad, we conducted a longitudinal survey study of 2630 students from 65 different US colleges and universities studying in 12 diverse locations abroad. Total drinks per week and heavy drinking days more than doubled while students were abroad, with heavier predeparture drinkers, men, and students under age 21 experiencing the greatest increases. There were few observed overall changes in alcohol-related consequences and risky sexual behaviors; however, specific groups, such as those with heavier predeparture consequences and sexual risk behaviors, men, and those on longer abroad programs reported greater consequences and risky sex abroad. One in five students (21%) experienced sexual violence abroad, with non-consensual physical contact the most prevalent form. Women, those under age 21, and those with a history of sexual violence were most likely to experience sexual violence abroad. Findings indicate that study abroad students may warrant targeted predeparture programming to help prevent heavy drinking and sexual violence experiences abroad.
Objectives To examine the effect of preoperative stent placement on total cost of ureteroscopic stone intervention. Passive ureteral dilation with a preoperative ureteral stent has been proposed as a ...method to facilitate both upper tract access and stone removal. Methods We retrospectively reviewed the records of patients who underwent ureteroscopic stone intervention at our institution from 2005 to 2009. A sample of patients who had undergone stenting before ureteroscopy was selected and nonstented matched controls were used as a comparison group. A cost model was used to compare the total healthcare costs for the prestented and nonstented patients with a large (>1 cm) and small (≤1 cm) stone burden using the actual cost accrued for each patient. Sensitivity analyses were used to examine the robustness of the cost model. Results A total of 104 patients were included in the present study (45 prestented, 59 not prestented). The median stone size was 1 cm (range 0.3-4). The overall stone clearance rate was 95.8%. The median number of procedures was 1. Pre-stenting significantly decreased the total healthcare cost in patients with stones >1 cm. The median cost for the prestented and nonstented cohorts was $17 706 and $27 806, respectively ( P < .01). However, prestenting increased the total cost for smaller stones of ≤1 cm, although not significantly. The median cost for the prestented and nonstented cohorts was $10 872 and $12 344, respectively ( P = .70). Sensitivity analysis confirmed that the model conclusions are robust. Conclusions Preoperative stent placement is cost-effective for successful ureteroscopic treatment of stones >1 cm.
Objective Treatment for advanced-stage epithelial ovarian cancer (AEOC) includes primary debulking surgery (PDS) or neoadjuvant chemotherapy (NACT). A randomized controlled trial comparing these ...treatments resulted in comparable overall survival (OS). Studies report more complications and lower chemotherapy completion rates in patients 65 years old or older receiving PDS. We sought to evaluate the cost implications of NACT relative to PDS in AEOC patients 65 years old or older. Study Design A 5 year Markov model was created. Arm 1 modeled PDS followed by 6 cycles of carboplatin and paclitaxel (CT). Arm 2 modeled 3 cycles of CT, followed by interval debulking surgery and then 3 additional cycles of CT. Parameters included OS, surgical complications, probability of treatment initiation, treatment cost, and quality of life (QOL). OS was assumed to be equal based on the findings of the international randomized control trial. Differences in surgical complexity were accounted for in base surgical cost plus add-on procedure costs weighted by occurrence rates. Hospital cost was a weighted average of diagnosis-related group costs weighted by composite estimates of complication rates. Sensitivity analyses were performed. Results Assuming equal survival, NACT produces a cost savings of $5616. If PDS improved median OS by 1.5 months or longer, PDS would be cost effective (CE) at a $100,000/quality-adjusted life-year threshold. If PDS improved OS by 3.2 months or longer, it would be CE at a $50,000 threshold. The model was robust to variation in costs and complication rates. Moderate decreases in the QOL with NACT would result in PDS being CE. Conclusion A model based on the RCT comparing NACT and PDS showed NACT is a cost-saving treatment compared with PDS for AEOC in patients 65 years old or older. Small increases in OS with PDS or moderate declines in QOL with NACT would result in PDS being CE at the $100,000/quality-adjusted life-year threshold. Our results support further evaluation of the effects of PDS on OS, QOL and complications in AEOC patients 65 years old or older.
Physician non-compliance with clinical practice guidelines remains a critical barrier to high quality care. Serious games (using gaming technology for serious purposes) have emerged as a method of ...studying physician decision making. However, little is known about their validity.
We created a serious game and evaluated its construct validity. We used the decision context of trauma triage in the Emergency Department of non-trauma centers, given widely accepted guidelines that recommend the transfer of severely injured patients to trauma centers. We designed cases with the premise that the representativeness heuristic influences triage (i.e. physicians make transfer decisions based on archetypes of severely injured patients rather than guidelines). We randomized a convenience sample of emergency medicine physicians to a control or cognitive load arm, and compared performance (disposition decisions, number of orders entered, time spent per case). We hypothesized that cognitive load would increase the use of heuristics, increasing the transfer of representative cases and decreasing the transfer of non-representative cases.
We recruited 209 physicians, of whom 168 (79%) began and 142 (68%) completed the task. Physicians transferred 31% of severely injured patients during the game, consistent with rates of transfer for severely injured patients in practice. They entered the same average number of orders in both arms (control (C): 10.9 SD 4.8 vs. cognitive load (CL):10.7 SD 5.6, p = 0.74), despite spending less time per case in the control arm (C: 9.7 SD 7.1 vs. CL: 11.7 SD 6.7 minutes, p<0.01). Physicians were equally likely to transfer representative cases in the two arms (C: 45% vs. CL: 34%, p = 0.20), but were more likely to transfer non-representative cases in the control arm (C: 38% vs. CL: 26%, p = 0.03).
We found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory.
This study protocol describes a proposed randomized controlled trial that builds upon a successful pilot intervention study to address problematic and dangerous drinking among young adult college ...students studying abroad in foreign environments. Despite universities and colleges citing alcohol misuse as the most concerning issue for their students abroad, most institutions offer no empirically-based prevention efforts tailored to this at-risk population. The proposed intervention attempts to fill a major gap for the nearly 333,000 students completing study abroad programs each year by using empirically-based and theoretically-informed risk and protective factors to correct misperceived peer drinking norms and promote cultural engagement abroad. In addition to preventing heavy and problematic drinking, the intervention seeks to prevent risky sexual behaviors (e.g., sex without a condom) and experience of sexual violence victimization, which are strikingly common among study abroad students and have the potential for lasting physical and psychological effects upon return home.
We will conduct a randomized controlled trial of an intervention with a sample of 1200 college students studying abroad from approximately 50 US universities and colleges. The brief, online intervention is text and video based and contains evidence-based components of personalized normative feedback to correct students' misperceived drinking norms, content to promote engagement with the cultural experience abroad and address difficulties adjusting to life in the foreign environment, and tips and strategies to prevent risky sexual behaviors and sexual violence victimization abroad. Participants will complete online surveys at five time points (predeparture, first month abroad, last month abroad, 1-month post-return, and 3-months post-return) to assess for intervention effects on drinking behavior, drinking consequences, risky sex, and sexual violence outcomes. We will examine whether the mechanisms targeted by the intervention (changes in perceived norms, engagement in the cultural experience abroad) serve as mediators of intervention efficacy.
The proposed study has the potential to fill an important gap in the research literature and provide empirical support for an online accessible, brief, and targeted approach that can easily be distributed to study abroad students to help prevent heavy alcohol use and sexual risk abroad. Trial registration ClinicalTrials.gov Identifier NCT03928067.
Objective: We evaluate a novel feedback-based procedure designed to enhance the accuracy of men's judgments of women's sexual interest in the laboratory, as misperception of sexual interest is ...implicated in male-initiated sexual aggression toward acquaintances. Method: In an initial rating task, 183 undergraduate males judged the sexual interest of women in full-body photographs; the women varied along sexual interest, clothing style, and attractiveness dimensions. Half of the participants received feedback on their ratings. In a related transfer task, participants indicated whether women in photographs would respond positively to a sexual advance. History of sexual aggression and rape-supportive attitudes were assessed. Results: Participants relied substantially on both affective and nonaffective cues when judging women's sexual interest. High-risk men relied less on affect and more on attractiveness. Feedback enhanced focus on women's affective cues and decreased focus on nonaffective cues for both low-risk and high-risk men. Feedback affected transfer performance indirectly, via altered cue usage in the training task. Conclusions: The current work documents high-risk men's altered focus on women's affective and nonaffective cues and provides encouraging support for the potential use of a cognitive-training paradigm to enhance men's perceptions of women's sexual-interest cues, albeit to a lesser degree for high-risk men.
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United States trauma system guidelines specify when to triage patients to specialty centers. Nonetheless, many eligible patients are not transferred as per guidelines. One possible reason is ...emergency physician decision-making. The objective of the study was to characterize sensory and decisional determinants of emergency physician trauma triage decision-making.
We conducted a decision science study using a signal detection theory-informed approach to analyze physician responses to a web-based survey of 30 clinical vignettes of trauma cases. We recruited a national convenience sample of emergency medicine physicians who worked at hospitals without level I/II trauma center certification. Using trauma triage guidelines as our reference standard, we estimated physicians' perceptual sensitivity (ability to discriminate between patients who did and did not meet guidelines for transfer) and decisional threshold (tolerance for false positive or false negative decisions).
We recruited 280 physicians: 210 logged in to the website (response rate 74%) and 168 (80%) completed the survey. The regression coefficient on American College of Surgeons--Committee on Trauma (ACS-COT) guidelines for transfer (perceptual sensitivity) was 0.77 (p<0.01, 95% CI 0.68-0.87) indicating that the probability of transfer weakly increased as the ACS-COT guidelines would recommend transfer. The intercept (decision threshold) was 1.45 (p<0.01, 95% CI 1.27-1.63), indicating that participants had a conservative threshold for transfer, erring on the side of not transferring patients. There was significant between-physician variability in perceptual sensitivity and decisional thresholds. No physician demographic characteristics correlated with perceptual sensitivity, but men and physicians working at non-trauma centers without a trauma-center affiliation had higher decisional thresholds.
On a case vignette-based questionnaire, both sensory and decisional elements in emergency physicians' cognitive processes contributed to the under-triage of trauma patients.
To describe lessons learned from the use of different strategies for recruiting physicians responsible for trauma triage, we summarize recruitment data from four behavioral trials run in the United ...States between 2010 and 2016.
We ran a series of behavioral trials with the primary objective of understanding the influence of heuristics on physician decision making in trauma triage. Three studies were observational; one tested an intervention. The trials used different methods of recruitment (in-person vs. email), timing of the honorarium (pre-paid vs. conditional on completion), type of honorarium a $100 gift card (monetary reward) vs. an iPad mini 2 (material incentive), and study tasks (a vignette-based questionnaire, virtual simulation, and intervention plus virtual simulation). We recruited 989 physicians, asking each to complete a questionnaire or virtual simulation online. Recruitment and response rates were 80% in the study where we approached physicians in person, used a pre-paid material incentive, and required that they complete both an intervention plus a virtual simulation. They were 56% when we recruited physicians via email, used a monetary incentive conditional on completion of the task, and required that they complete a vignette-based questionnaire. Trial registration clinicaltrials.gov; NCT02857348.
The U.S. Department of Defense established the National Intrepid Center of Excellence (NICoE) to provide specialized services for troops suffering from traumatic brain injury (TBI). Through ...interviews with NICoE staff, home station providers, service members treated at the NICoE, and their families, as well as surveys and site visits, RAND evaluated interactions between the NICoE and providers referring patients and implementing treatment plans.
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