Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy

BackgroundAudit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study.MethodsWe undertook a qualitative study exploring A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six English National Health Service endoscopy centres, purposively sampled for professional background and experience. A thematic framework analysis was performed, mapping paradoxical effects and harms using FIT and the theory of planned behaviour.ResultsData saturation was achieved on the 19th participant, with participants from nursing, surgical and medical backgrounds and a median of 7 years’ experience.When performance was below aspirational targets participants were falsely reassured by social comparisons. Participants described confidence as a requirement for colonoscopy. Negative feedback without a plan to improve risked reducing confidence and impeding performance (cognitive interference). Unmet targets increased anxiety and prompted participants to question messages’ motives and consider gaming.Participants described inaccurate documentation of subjective measures, including patient comfort, to achieve targets perceived as important. Participants described causing harm from persevering to complete procedures despite patient discomfort and removing insignificant polyps to improve detection rates without benefiting the patient.ConclusionOur dark logic model highlighted that A&F interventions may create both desired and adverse effects. Without a priori theorisation evaluations may disregard potential harms. In colonoscopy, improved patient experience measures may reduce harm. To address cognitive interference the motivation of feedback to support improvement should always be clear, with plans targeting specific behaviours and offering face-to-face support for confidence.Trial registration numberISRCTN11126923.

Impact of inspiratory threshold loading on brain activity and cognitive performances in healthy humans

In healthy humans, inspiratory threshold loading deteriorates cognitive performances. This can result from motor-cognitive interference (activation of motor respiratory-related cortical networks vs. executive resources allocation), sensory-cognitive interference (dyspnea vs. shift in attentional focus), or both. We hypothesized that inspiratory loading would concomitantly induce dyspnea, activate motor respiratory-related cortical networks, and deteriorate cognitive performance. We reasoned that a concomitant activation of cortical networks and cognitive deterioration would be compatible with motor-cognitive interference, particularly in case of a predominant alteration of executive cognitive performances. Symmetrically, we reasoned that a predominant alteration of attention-depending performances would suggest sensory-cognitive interference. Twenty-five volunteers (12 men; 19.5-51.5 years) performed the Paced Auditory Serial Addition test (PASAT-A and B; calculation capacity, working memory, attention), the Trail Making Test (TMT-A, visuospatial exploration capacity; TMT-B, visuospatial exploration capacity and attention), and the Corsi block-tapping test (visuospatial memory, short-term and working memory) during unloaded breathing and inspiratory threshold loading in random order. Loading consistently induced dyspnea and respiratory-related brain activation. It was associated with deteriorations inPASAT A (52 [45.5;55.5] (median [interquartile range]) to 48 [41;54.5], p=0.01), PASAT B (55 [47.5;58] to 51 [44.5;57.5], p=0.01), and TMT B (44s [36;54.5] to 53s [42;64], p=0.01), but did not affect TMT-A and Corsi. The concomitance of cortical activation and cognitive performance deterioration is compatible with competition for cortical resources (motor-cognitive interference), while the profile of cognitive impairment (PASAT and TMT-B but not TMT-A and Corsi) is compatible with a contribution of attentional distraction (sensory-cognitive interference). Both mechanisms are therefore likely at play.

Auditory Brainstem Response with Cognitive Interference in Normal and Autism Spectrum Disorder Children - Understanding the Auditory Sensory Gating Mechanism

Earlier studies disputed the influence of higher-order function such as attention or cognitive inhibition on the auditory brainstem response (ABR) result. In short, the ABR result was considered similar with or without the subject paying attention. However, in the last few years, there has been growing evidence that the higher-order function may influence the ABR findings provided the sensory gating system of the brain is triggered by any cognitive interference activities. This chapter will explain the concept of auditory sensory gating, a method to measure auditory sensory gating, and at the end of the chapter, preliminary findings concerning the ABR with cognitive interference among ten normally developing children are presented. This chapter will also share a case study that compared auditory sensory gating capacity in normal and children with mild autism spectrum disorder (ASD).

Cognitive interference processing in adults with childhood craniopharyngioma using functional magnetic resonance imaging

Purpose To assess cognitive interference processing in adults with childhood craniopharyngioma (CP), with and without hypothalamic injury, respectively, in terms of behavioral performance and functional magnetic resonance imaging (fMRI) activity, using the multi-source interference task (MSIT). Methods Twenty-eight CP patients (median age 34.5 [29.0–39.5] years) were investigated at median 20.5 (16.3–28.8) years after treatment with surgical resection and in some cases additional radiotherapy (n = 10) and compared to 29 matched controls (median age 37.0 [32.5–42.0] years). The subjects performed the MSIT during fMRI acquisition and behavioral performance in terms of response times (ms) and accuracy performance (%) were recorded. Results The MSIT activated the cingulo-fronto-parietal (CFP) attention network in both CP patients and controls. No differences were found in behavioral performance nor fMRI activity between CP patients (interference effect 333.9 [287.3–367.1] ms and 3.1 [1.6–5.6]%, respectively) and controls (309.1 [276.4–361.0] ms and 2.6 [1.6–4.9]%). No differences were found in behavioral performance nor fMRI activity between the two subgroups with (332.0 [283.6–353.4] ms and 4.2 [2.3–5.7]%, respectively) and without hypothalamic injury (355.7 [293.7–388.7] ms and 2.1 [1.0–5.2]%, respectively), respectively, and controls. Conclusion Adults with childhood CP performed cognitive interference processing equally well as controls and demonstrated no compensatory fMRI activity in the CFP attention network compared to controls. This was also true for the two subgroups with and without hypothalamic injury. The results can be useful to better characterize this condition, and to optimize treatment and support for these individuals.

Examination of Test Anxiety in a Sample of 18 to 26 year-old Singapore and U.S. Undergraduate Male and Female Students on the Test Anxiety Measure for College Students-Short Form

A cross-national study was conducted on a new test anxiety measure, the Test Anxiety Measure for College Students-Short Form (TAMC-SF) in a sample of 1,023 Singapore and U.S. students, aged 18-26. The TAMC-SF consists of one facilitating anxiety scale and five test anxiety (Worry, Cognitive Interference, Social Concerns, Physiological Hyperarousal, and Task Irrelevant Behaviors) scales. The measure was administered to the sample of higher education students online. The results of single-group confirmatory factor analyses found support for the TAMC-SF six-factor model for Singapore students, U.S. students, male students, and female students. In addition, the results of multi-group, mean and covariance structure analysis found support for the construct equivalency of the TAMC-SF scores across country and gender. Latent mean factor analyses followed and the results of these analyses indicated Singapore students had significantly higher levels of social concerns and significantly lower levels of cognitive interference and worry than U.S. students. The findings also indicated females had significantly higher levels of test anxiety than males on all five TAMC-SF test anxiety scales. Evidence supporting the construct validity of the TAMC-SF scores with the scores of math anxiety, social phobia, and self-critical perfectionism was also reported. Implications of the study’s findings for researchers and clinicians are discussed.

A cognitive interference model of sexual functioning for gay men: the relationship between internalized homophobia and erectile function

Gay men more frequently report erectile difficulties than heterosexual men, possibly due to the additional stress gay men experience as a result of their sexual minority status. Internalized homophobia (IH), defined as the internalization of negative societal attitudes about being gay, is associated with adverse sexual outcomes. However, the mechanisms underlying this relationship remain unclear. According to Barlow’s model of sexual dysfunction, cognitive interference plays a key role in the development and maintenance of erectile dysfunction. The present study examined the cross-sectional and longitudinal relationships between IH, cognitive anxiety symptoms, and erectile function in a sample of 252 HIV-negative gay and bisexual men. Participants completed a battery of self-report questionnaires assessing internalized homophobia, cognitive anxiety symptoms, and erectile functioning at baseline, 3-month, and 6-month follow-ups. Cognitive anxiety symptoms did not mediate the relationship between IH and erectile function at baseline or across 6-months. Limitations and future directions are discussed.

A cognitive interference model of sexual functioning for gay men: the relationship between internalized homophobia and erectile function

Gay men more frequently report erectile difficulties than heterosexual men, possibly due to the additional stress gay men experience as a result of their sexual minority status. Internalized homophobia (IH), defined as the internalization of negative societal attitudes about being gay, is associated with adverse sexual outcomes. However, the mechanisms underlying this relationship remain unclear. According to Barlow’s model of sexual dysfunction, cognitive interference plays a key role in the development and maintenance of erectile dysfunction. The present study examined the cross-sectional and longitudinal relationships between IH, cognitive anxiety symptoms, and erectile function in a sample of 252 HIV-negative gay and bisexual men. Participants completed a battery of self-report questionnaires assessing internalized homophobia, cognitive anxiety symptoms, and erectile functioning at baseline, 3-month, and 6-month follow-ups. Cognitive anxiety symptoms did not mediate the relationship between IH and erectile function at baseline or across 6-months. Limitations and future directions are discussed.