AscitesNCT01403987
Improving Performance of Paracentesis in Medical Residency Training
A study testing Residency Program Teaching, Lecture and Pocket Card Reference in people with Ascites and Cirrhosis, run by Boston Medical Center at 1 site in United States.
Trial summary
The investigators hypothesize that there is significant variability in management of patients with ascites despite guidelines provided by the American Association for the Study of Liver Diseases, the professional organization most involved with management of liver patients. Read more about this study
- Who is it for?
- Any age
- What is being tested?
- Residency Program Teaching, Lecture and Pocket Card Reference
- Type of treatment
- Lifestyle or therapy programme
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 136 participants
- Where
- 1 siteUnited States
- Study dates
- Jan 2011to Mar 2012
- Phase
- Interventional
- Are there results?
- Yes, posted in the registrySummary in the doctors' view
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages Any age
- All sexes
- No healthy volunteers
- Child, Adult, Older adult
Who may be able to join
- All house-staff in the Internal Medicine Residency training program at Boston Medical Center; House-staff participating in Internal Medicine inpatient rotations as part of preliminary training for other specialties
Who cannot join
- House-staff participating in inpatient rotations not supervised by the Department of Internal Medicine
Trial locations and contacts
1 site in 1 country.
About this study
The investigators hypothesize that there is significant variability in management of patients with ascites despite guidelines provided by the American Association for the Study of Liver Diseases, the professional organization most involved with management of liver patients. This variability may be attributable to knowledge deficits, skill limitations, or reflect systems-issues that limit the ability of a care provider to implement the clinical guidelines (time constraints, inadequate supervision, availability of appropriate equipment, and obtaining consent for non-emergent procedures). This variability does a disservice to the patients being treated, and results in trainee development of habits that are not evidence based. There are simple teaching tools available that may improve learning and retention of evidence based practice. Using these tools should result in more consistent appropriate patient care, improve patient outcomes, and provide better education to our trainees.
The purpose of this study is threefold: 1. To improve medical house-staff's technical performance of and comfort level with paracentesis; 2. To improve adherence to professional organization guidelines and to determine if this in fact improves clinical outcomes; 3. To evaluate efficacy of three teaching interventions in inpatient medicine trainee rotations.
Read the detailed description
Since 2004 the American Association for the Study of Liver Disease (AASLD) has well-established guidelines for management of liver failure patients that is based on expert review of current literature. These guidelines address the initial evaluation of patients admitted to the hospital with complications of their liver disease, including patients with abdominal distention from fluid accumulation. In many cases, evaluation of this intraabdominal fluid, or ascites, performed using paracentesis, a procedure in which fluid is withdrawn from the abdomen and sent for laboratory analysis, is indicated, and the results of which will guide further treatment. Despite these guidelines, there remains significant variability in practice among inpatient providers.
The study will begin with a chart review to identify compliance with, and barriers to, evidence-based recommendations. A baseline survey of house-staff in the internal medicine department will be used to identify knowledge base and perceived barriers to implementation of best practices as defined by AASLD. The house-staff will subsequently be divided into three intervention groups for administration and evaluation of different teaching tools. A control group will have internet access to AASLD guidelines and undergo teaching that is already provided by the residency program. The second group will receive the baseline teaching, but also receive a pocket-card outlining recommendations and participate in a short, dedicated lecture to reinforce the guidelines. The third group will receive the pocket card, lecture, and a pager number to call for individual education at the time that cases arise. The groups will be followed for a period of six months, after which they will participate in an exit survey for reassessment of knowledge and perceived barriers, and a chart review will be conducted for comparison of data.
The primary outcome will be subjective improvement in practice based on survey results. Secondary outcomes will be measurement of actual and perceived benefit of pocket card, lecture, and individual education, determined by knowledge based questions on the survey, and improvement in patient clinical outcomes based on chart review noting particularly 30-day readmission rate and 90-day mortality.
- Being tested
- Residency Program Teaching, Lecture, Pocket Card Reference, Pager
- Keywords
- Education, Ascites, Liver, Guidelines
- Medical subject headings
- Ascites, Fibrosis
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Residency Program TeachingBehavioural
Also called Standard therapy
The residency program provides education surrounding the management of ascites to all house-staff in the training program. This consists of lectures, case-based or bedside discussions, and board review. All arms will receive the standard teaching provided by the residency program.
LectureBehavioural
Also called Didactic session
During resident rotations on inpatient wards there are typically several dedicated, one-hour discussions facilitated by the team's supervising attending, addressing a variety of internal medicine topics. In place of or in addition to one of these discussions, a gastroenterology fellow will meet with the team for one hour to discuss a standardized case of a patient with ascites and the management issues. At this time they will review the consensus guidelines for management, and be provided with a pocket card with key points.
Pocket Card ReferenceOther
Also called Visual aid
A 4x6 inch laminated card will be administered to both intervention arms at the beginning of the study. The card will contain a brief summary of AASLD guidelines, indications for and contraindications to paracentesis, and key studies to order for fluid analysis. The organization of residency rotations is such that members of one randomization group do not typically work with members of other groups, however in the event that there is crossover, they will be free to share information as they see fit in order to optimize patient care.
PagerBehavioural
Also called One-on-one teaching
The intensive education arm will be given a pager number at their initial meeting that they can use to call for personal assistance with performing paracentesis. Since a paracentesis is frequently referred to by housestaff as a "tap," the pager number will correlate with the letters, "TAPS," or #8277. The goal of the pager is to provide supervision and individual teaching so that the care provider can become proficient in the procedure.
| Study group | Role | What they receive |
|---|---|---|
| Control Arm | Active comparator | Control group will receive standard teaching by the Residency Program regarding management of ascites and performance of paracentesis. Receives: Behavioral: Residency Program Teaching |
| Intermediate Education Arm | Experimental | In addition to the teaching provided by the residency program, the intermediate education group will receive a dedicated lecture by a gastroenterology fellow designed to teach consensus guidelines and their rationale in management of ascites. They will also receive a pocket card noting specific indications for paracentesis, and a brief summary of guidelines. Receives: Behavioral: Residency Program Teaching; Behavioral: Lecture; Other: Pocket Card Reference |
| Intensive Education Arm ("Pager" Arm) | Experimental | This group will receive the residency teaching, the specialist lecture, the pocket card, and have access to a pager carried by a gastroenterology fellow for personal assistance in performing paracentesis. Receives: Behavioral: Residency Program Teaching; Behavioral: Lecture; Other: Pocket Card Reference; Behavioral: Pager |
What is being measured
The primary outcome is the main question the study is designed to answer.
Score Out of Total Possible 25 on a Likert Scale.
Primary outcome is quantified by summation of Likert scale responses to five questions assessing for comfort level in caring for and managing inpatients with ascites. The scale ranges from "strongly disagree," which is assigned a value of 1, to "strongly agree," assigned a value of 5. The summation scores will therefore range from 5 to 25 points out of a total of 25 possible points. The post-intervention scores will be compared between groups using a multiple regression model with terms for treatment, baseline summary scores, and other baseline demographic variables as needed.
Measured: 6 months
Secondary outcomes (2)
Improvement in Guideline Adherence
Improvement in adherence to AASLD guidelines is summarized as yes or no improvement based on investigator chart review performed prior to and after the intervention. This is not a measure of resident reporting adherence but rather investigator interpretation of patient care and whether care was in line with published guidelines.
Measured: 18 months
Readmission and Mortality Rates
Percentage of patients in each arm that were either readmitted within 30 days or died within 90 days (ie a combined endpoint of either/or readmission or death)
Measured: 18 months
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted27 Jul 2011 (estimated)
- Study startJan 2011
- Primary completionMar 2012
- Study completionMar 2012
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Posted resultsParticipant flow, outcome measures and adverse events reported by the sponsor.
- Publications (5)Papers the sponsor has linked to this study.
- Other trials for AscitesStudies of the same condition, open and under way.
- More trials run by Boston Medical CenterThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 136 participants (actual)
Sponsor and investigators
- Lead sponsor
- Boston Medical Center
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Brian Jacobson, Boston Medical Center
- Investigators
- Brian Jacobson, MD, Principal investigator, Boston Medical Center
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT01403987
- Sponsor's protocol ID
- H-29983
- Status last verified
- Sep 2012
- First submitted
- 26 Jul 2011
- Last updated
- 31 Oct 2012
- Results posted
- Yes, on ClinicalTrials.gov
- Data monitoring committee
- No
Publications
Runyon BA; AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009 Jun;49(6):2087-107. doi: 10.1002/hep.22853. No abstract available.
PubMed 19475696Kashner TM, Henley SS, Golden RM, Byrne JM, Keitz SA, Cannon GW, Chang BK, Holland GJ, Aron DC, Muchmore EA, Wicker A, White H. Studying the effects of ACGME duty hours limits on resident satisfaction: results from VA learners' perceptions survey. Acad Med. 2010 Jul;85(7):1130-9. doi: 10.1097/ACM.0b013e3181e1d7e3.
PubMed 20592508Chahla M, Eberlein M, Wright S. The effect of providing a USB syllabus on resident reading of landmark articles. Med Educ Online. 2010 Jan 29;15. doi: 10.3402/meo.v15i0.4639.
PubMed 20165697Tomolo A, Caron A, Perz ML, Fultz T, Aron DC. The outcomes card. Development of a systems-based practice educational tool. J Gen Intern Med. 2005 Aug;20(8):769-71. doi: 10.1111/j.1525-1497.2005.0168.x.
PubMed 16050891Walton JM, Steinert Y. Patterns of interaction during rounds: implications for work-based learning. Med Educ. 2010 Jun;44(6):550-8. doi: 10.1111/j.1365-2923.2010.03626.x.
PubMed 20604851
Study at a glance
From the registry record, last updated by the sponsor on 31 Oct 2012. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Improving Performance of Paracentesis in Medical Residency Training
- ClinicalTrials.gov ID
- NCT01403987
- Acronym / sponsor ID
- H-29983
- Keywords
- Education, Ascites, Liver, Guidelines
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 136 participants (actual)
- Lead sponsor
- Boston Medical CenterUniversity, hospital or other
- Study start
- Jan 2011
- Primary completion
- Mar 2012 (actual)
- Study completion
- Mar 2012 (actual)
- First posted
- 27 Jul 2011 (estimated)
- Results
- Posted 31 Oct 2012
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The investigators hypothesize that there is significant variability in management of patients with ascites despite guidelines provided by the American Association for the Study of Liver Diseases, the professional organization most involved with management of liver patients. This variability may be attributable to knowledge deficits, skill limitations, or reflect systems-issues that limit the ability of a care provider to implement the clinical guidelines (time constraints, inadequate supervision, availability of appropriate equipment, and obtaining consent for non-emergent procedures). This variability does a disservice to the patients being treated, and results in trainee development of habits that are not evidence based. There are simple teaching tools available that may improve learning and retention of evidence based practice. Using these tools should result in more consistent appropriate patient care, improve patient outcomes, and provide better education to our trainees.
The purpose of this study is threefold: 1. To improve medical house-staff's technical performance of and comfort level with paracentesis; 2. To improve adherence to professional organization guidelines and to determine if this in fact improves clinical outcomes; 3. To evaluate efficacy of three teaching interventions in inpatient medicine trainee rotations.
Detailed description
Since 2004 the American Association for the Study of Liver Disease (AASLD) has well-established guidelines for management of liver failure patients that is based on expert review of current literature. These guidelines address the initial evaluation of patients admitted to the hospital with complications of their liver disease, including patients with abdominal distention from fluid accumulation. In many cases, evaluation of this intraabdominal fluid, or ascites, performed using paracentesis, a procedure in which fluid is withdrawn from the abdomen and sent for laboratory analysis, is indicated, and the results of which will guide further treatment. Despite these guidelines, there remains significant variability in practice among inpatient providers.
The study will begin with a chart review to identify compliance with, and barriers to, evidence-based recommendations. A baseline survey of house-staff in the internal medicine department will be used to identify knowledge base and perceived barriers to implementation of best practices as defined by AASLD. The house-staff will subsequently be divided into three intervention groups for administration and evaluation of different teaching tools. A control group will have internet access to AASLD guidelines and undergo teaching that is already provided by the residency program. The second group will receive the baseline teaching, but also receive a pocket-card outlining recommendations and participate in a short, dedicated lecture to reinforce the guidelines. The third group will receive the pocket card, lecture, and a pager number to call for individual education at the time that cases arise. The groups will be followed for a period of six months, after which they will participate in an exit survey for reassessment of knowledge and perceived barriers, and a chart review will be conducted for comparison of data.
The primary outcome will be subjective improvement in practice based on survey results. Secondary outcomes will be measurement of actual and perceived benefit of pocket card, lecture, and individual education, determined by knowledge based questions on the survey, and improvement in patient clinical outcomes based on chart review noting particularly 30-day readmission rate and 90-day mortality.
Study design
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Number of arms
- 3
| Arm | Type | Receives |
|---|---|---|
| Control Arm | Active comparator | Behavioral: Residency Program TeachingControl group will receive standard teaching by the Residency Program regarding management of ascites and performance of paracentesis. |
| Intermediate Education Arm | Experimental | Behavioral: Residency Program Teaching, Behavioral: Lecture, Other: Pocket Card ReferenceIn addition to the teaching provided by the residency program, the intermediate education group will receive a dedicated lecture by a gastroenterology fellow designed to teach consensus guidelines and their rationale in management of ascites. They will also receive a pocket card noting specific indications for paracentesis, and a brief summary of guidelines. |
| Intensive Education Arm ("Pager" Arm) | Experimental | Behavioral: Residency Program Teaching, Behavioral: Lecture, Other: Pocket Card Reference, Behavioral: PagerThis group will receive the residency teaching, the specialist lecture, the pocket card, and have access to a pager carried by a gastroenterology fellow for personal assistance in performing paracentesis. |
Who may qualify
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Child, Adult, Older adult
Key inclusion criteria (1 listed)
- All house-staff in the Internal Medicine Residency training program at Boston Medical Center; House-staff participating in Internal Medicine inpatient rotations as part of preliminary training for other specialties
Key exclusion criteria (1 listed)
- House-staff participating in inpatient rotations not supervised by the Department of Internal Medicine
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Residency Program TeachingAlso: Standard therapyThe residency program provides education surrounding the management of ascites to all house-staff in the training program. This consists of lectures, case-based or bedside discussions, and board review. All arms will receive the standard teaching provided by the residency program. | Behavioural | Control Arm, Intensive Education Arm ("Pager" Arm), Intermediate Education Arm |
| LectureAlso: Didactic sessionDuring resident rotations on inpatient wards there are typically several dedicated, one-hour discussions facilitated by the team's supervising attending, addressing a variety of internal medicine topics. In place of or in addition to one of these discussions, a gastroenterology fellow will meet with the team for one hour to discuss a standardized case of a patient with ascites and the management issues. At this time they will review the consensus guidelines for management, and be provided with a pocket card with key points. | Behavioural | Intensive Education Arm ("Pager" Arm), Intermediate Education Arm |
| Pocket Card ReferenceAlso: Visual aidA 4x6 inch laminated card will be administered to both intervention arms at the beginning of the study. The card will contain a brief summary of AASLD guidelines, indications for and contraindications to paracentesis, and key studies to order for fluid analysis. The organization of residency rotations is such that members of one randomization group do not typically work with members of other groups, however in the event that there is crossover, they will be free to share information as they see fit in order to optimize patient care. | Other | Intensive Education Arm ("Pager" Arm), Intermediate Education Arm |
| PagerAlso: One-on-one teachingThe intensive education arm will be given a pager number at their initial meeting that they can use to call for personal assistance with performing paracentesis. Since a paracentesis is frequently referred to by housestaff as a "tap," the pager number will correlate with the letters, "TAPS," or #8277. The goal of the pager is to provide supervision and individual teaching so that the care provider can become proficient in the procedure. | Behavioural | Intensive Education Arm ("Pager" Arm) |
Primary outcome
Score Out of Total Possible 25 on a Likert Scale.
Time frame: 6 months
Primary outcome is quantified by summation of Likert scale responses to five questions assessing for comfort level in caring for and managing inpatients with ascites. The scale ranges from "strongly disagree," which is assigned a value of 1, to "strongly agree," assigned a value of 5. The summation scores will therefore range from 5 to 25 points out of a total of 25 possible points. The post-intervention scores will be compared between groups using a multiple regression model with terms for treatment, baseline summary scores, and other baseline demographic variables as needed.
2 secondary outcomes
Improvement in Guideline Adherence
Time frame: 18 months
Readmission and Mortality Rates
Time frame: 18 months
Results and safety
Loading the posted results from ClinicalTrials.gov…
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 31 Oct 2012.
- Posted resultsParticipant flow, baseline, all outcome measures and adverse events.
- Background: PubMed 19475696Runyon BA; AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009 Jun;49(6):2087-107. doi: 10.1002/hep.22853. No abstract available.
- Background: PubMed 20592508Kashner TM, Henley SS, Golden RM, Byrne JM, Keitz SA, Cannon GW, Chang BK, Holland GJ, Aron DC, Muchmore EA, Wicker A, White H. Studying the effects of ACGME duty hours limits on resident satisfaction: results from VA learners' perceptions survey. Acad Med. 2010 Jul;85(7):1130-9. doi: 10.1097/ACM.0b013e3181e1d7e3.
- Background: PubMed 20165697Chahla M, Eberlein M, Wright S. The effect of providing a USB syllabus on resident reading of landmark articles. Med Educ Online. 2010 Jan 29;15. doi: 10.3402/meo.v15i0.4639.
- Background: PubMed 16050891Tomolo A, Caron A, Perz ML, Fultz T, Aron DC. The outcomes card. Development of a systems-based practice educational tool. J Gen Intern Med. 2005 Aug;20(8):769-71. doi: 10.1111/j.1525-1497.2005.0168.x.
- Background: PubMed 20604851Walton JM, Steinert Y. Patterns of interaction during rounds: implications for work-based learning. Med Educ. 2010 Jun;44(6):550-8. doi: 10.1111/j.1365-2923.2010.03626.x.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Brian Jacobson, MD principal investigator
Boston Medical Center
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Residency Program Teaching, Lecture and Pocket Card Reference in people with Ascites and Cirrhosis, run by Boston Medical Center at 1 site in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 1 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 31 Oct 2012. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
Yes. Results are posted in the registry (first posted 31 Oct 2012). A summary is in the For doctors view, and the full results are on ClinicalTrials.gov.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Score Out of Total Possible 25 on a Likert Scale. (time frame: 6 months). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT01403987, which also lists 5 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 31 Oct 2012.