Browsing by Author "Harvey, Adrian"
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- ItemOpen AccessCost-effectiveness analysis of molecular testing for cytologically indeterminate thyroid nodules(2022-12-21) Dharampal, Navjit; Smith, Kristine; Harvey, Adrian; Paschke, Ralf; Rudmik, Luke; Chandarana, ShamirAbstract Background Thyroid nodules affect up to 65% of the population. Although fine needle aspirate (FNA) cytology is the gold standard for diagnosis, 15–30% of results are indeterminate. Molecular testing may aid in the diagnosis of nodules and potentially reduce unnecessary surgery. However, these tests are associated with significant costs. The objective of this study was to evaluate the cost-effectiveness of Afirma, a commercially available molecular test, in cytologically indeterminate thyroid nodules. Methods The base case was a solitary thyroid nodule with no additional high-risk features and an indeterminate FNA. Decision tree analysis was performed from the single payer perspective with a 1-year time horizon. Costing data were collected through micro-costing methodology. A probabilistic sensitivity analysis was performed. The primary outcome was the incremental cost effectiveness ratio (ICER) of cost per thyroid surgery avoided. Results Over 1 year, mean cost estimates were $8176.28 with 0.58 effectiveness for the molecular testing strategy and $6016.83 with 0.07 effectiveness for current standard management. The ICER was $4234.22 per surgery avoided. At a willingness-to-pay (WTP) threshold of $5000 per surgery avoided, molecular testing is cost-effective with 63% certainty. Conclusion This cost-effectiveness analysis suggests utilizing Afirma for indeterminate solitary thyroid nodules is a cost-effective strategy for avoiding unnecessary thyroid surgery. With a $5000 WTP threshold, molecular testing has a 63% chance of being the more cost-effective strategy. The cost effectiveness varies based on the cost of the molecular test and the value of Afirma for patients with indeterminate thyroid nodules depends on the WTP threshold to avoid unnecessary thyroid surgery. Graphical Abstract
- ItemOpen AccessThe Impact of Content Specific Resident Teaching on the Knowledge and Clinical Skills of Medical Students(2021-08) Zondervan, Nathan; McLaughlin, Kevin; Ma, Irene; Harvey, Adrian; Oddone Paolucci, ElizabethResidents are positioned to create safe learning environments where medical students are comfortable asking questions and presenting ideas. However, residents frequently teach without training or confidence in their teaching ability. Resident-as-teacher training improves observed teaching skill, but little is known about their impact on medical student learning. A realist review was conducted to describe the impact of resident-as-teacher training on the knowledge, skills, and perceptions of medical students. Studies reporting medical student outcomes following exposure to trained resident-teachers were identified in five databases and independently reviewed by two investigators. Analysis of contextual factors suggested that longer, dispersed, and mandatory interventions that targeted a larger number of residents with low prior ratings of teaching effectiveness were more likely to show a positive effect on student ratings of resident teaching. The provision of highly rated training sessions that improve residents’ confidence and self-ratings of teaching ability was the proposed mechanism. There were no studies that elicited changes in medical student knowledge or skills, suggesting that improved teaching ability may not translate into improved student performance unless the content of the teaching is congruent with the examination. A sequential explanatory mixed methods study was then completed to explore the impact of introducing a resident-led and content specific curriculum on medical student performance on certifying examinations. Quantitative analysis demonstrated an increased percentage of medical students passing the surgery OSCE station. However, there was no difference in performance on the surgery MCQ or student ratings of resident teaching. Student ratings of the surgery rotation significantly declined. Qualitative analysis of medical student and resident focus groups revealed poor utilization of the curriculum resources designed for knowledge transfer, while the clinical skills elements were readily integrated into clinical activities. Overall, resident-as-teacher training can improve medical student perceptions of resident-led teaching, but independently have little effect on measures of knowledge and skill. Providing residents with learning objectives and teaching resources that are appropriate for the clinical environment can improve medical student performance on standardized examinations. Creating the time required to address the learning needs of medical students remains an ongoing barrier to teaching amid busy clinical rotations.