Abstract
Background
A 3-dimensional understanding of hypoplastic left heart syndrome (HLHS) and its stages of surgical palliation is crucial for pediatric cardiology trainees. Virtual reality has been used in surgical and medical fields for teaching of anatomy and physiology. An HLHS virtual reality curriculum is under development and requires a validated method to measure knowledge acquisition.
Objectives
Develop and validate a multimedia assessment tool aimed at evaluating trainee knowledge of HLHS anatomy, physiology, and clinical concepts.
Methods
Educational domains across each stage of HLHS palliation were identified, including anatomy, physiology, and important clinical concepts. Six cardiologists and fellows developed multiple-choice multimedia questions based on the educational domains. Six content experts took the assessment, rated question relevance to educational domains, and provided qualitative feedback. An item-level content validity index (I-CVI) was calculated for each question. Any questions with ≤50 % correct responses or I-CVI <0.78 was removed. Scale-level content validity index (S-CVI) was determined for the final assessment tool, and S-CVI ≥0.90 was deemed excellent.
Results
A 33-question assessment tool was developed and distributed to the content experts. The average score was 97.0 %, with only four questions having incorrect answers. No questions had ≤50 % correct responses. I-CVI was <0.78 for two questions, and one question was removed due to repetition. The S-CVI was 0.97. Qualitative feedback revealed two themes that were subsequently addressed: marginal image and video quality for certain questions and the exclusive use of hemi‐Fontan and bidirectional Glenn to describe stage II procedures. Following these changes, a final 30-question validated assessment tool was created.
Conclusion
Evaluation of new curricula is aided by use of validated methods for assessment. Here, we demonstrate an effective iterative method for developing and validating an assessment tool to evaluate trainee knowledge of HLHS and its stages of surgical palliation.
Highlights
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We aimed to develop a validated assessment tool to measure knowledge of HLHS.
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Educational domains for HLHS teaching include anatomy, physiology, and clinical concepts.
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Content validity was derived using content expert feedback.
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A 30-question validated multimedia assessment tool was developed.
1
Introduction
A 3-dimensional (3D) understanding of cardiac anatomy is crucial for pediatric cardiology trainees but can be difficult to attain. Generating a mental 3D model of congenital heart defects requires the trainee to pair anatomic and physiologic concepts with knowledge of different imaging modalities (echocardiograms, angiograms, and cross-sectional imaging). For trainees, the basic learning of these modalities must occur alongside their application to anatomy and physiology. Ultimately, these concepts must be applied meaningfully to patient care. Studies in pediatric residents have shown the move toward multi-modal teaching of cardiology has been positively received [ ]. Virtual reality (VR), in particular, has been shown to be an effective means of teaching anatomy [ , ] and cardiac physiology [ ]. Many surgical specialties are also using VR to teach and practice surgical techniques [ , ]. Pediatric cardiologists may be able to utilize these benefits of VR education to augment their 3D understanding of congenital heart defects and their palliations and/or repairs.
Pediatric cardiologists commonly care for patients with single ventricle heart disease. Hypoplastic left heart syndrome (HLHS) is a common diagnosis within this category and its surgical palliative strategy provides conceptual framework for the clinical approach used with many other single ventricle anatomies. Children with HLHS typically undergo three stages of surgical palliation, culminating in the Fontan procedure by approximately 5 years of life. A strong 3D understanding of this lesion, its nuances, and its multiple stages of surgical palliation are important but difficult to grasp early in training. Pursuant to this notion, efforts are currently underway to develop a virtual reality program for pediatric cardiology trainees (Michigan Anatomic Congenital Heart in 3D [MACH-3]). However, implementation of curricula requires a robust means of measuring attributable knowledge acquisition. In the effort described herein, we describe development and validation of a multimedia assessment tool aimed at evaluating trainee knowledge of HLHS. This assessment tool may be used in future efforts to evaluate efficacy of new VR-based curricula or other curricula aimed at teaching concepts related to management and surgical palliation of HLHS.
2
Methods
2.1
Assessment tool creation
Pediatric cardiologists and fellows from a total of five different institutions were included throughout the development and validation of this tool. Targeted educational domains of the MACH-3 curriculum were created. The three domains included anatomy, physiology, and clinical concepts, each applied to unpalliated anatomy and the three palliative stages. The final educational domains and components are shown in Table 1 . Utilizing this framework, multiple choice questions equally distributed between the domains were developed to assess this knowledge, with an emphasis placed on 3D understanding of the lesion. Questions including images and/or videos require understanding of the image to accurately answer the question. After collating the questions and removing duplicated items, a total of 33 questions were finalized. The questions were enhanced by adding supporting radiographic, echocardiographic, and angiographic video clips. The assessment tool was platformed within Research Electronic Data Capture (RedCap) hosted at the University of Michigan. The study was deemed exempt by the University of Michigan Institutional Review Board, and consent was not required.
| Anatomy | Physiology | Clinical concepts | |
|---|---|---|---|
| Unpalliated HLHS | Underdeveloped LV Hypoplastic aorta ASD PDA | Need for ASD Need for PDA Coronary flow | PGE1 importance PGE1 side effects Intervention in days |
| Stage 1 palliation | mBTT vs RV-PA shunt anatomy Reconstructed arch Atrial septectomy Systemic RV | mBTT vs RV-PA shunt flow Atrial mixing Unobstructed outflow Unobstructed atrial mixing Restricted pulmonary flow | Expected SpO2 Timing of surgery Circulatory balance Shunt size |
| Stage 2 palliation | Stage 2 anatomy Shunt takedown IVC remains to RA | Passive flow to lungs Atrial mixing | Expected SpO2 Timing of surgery Volume unloading RV |
| Stage 3 palliation | IVC to pulmonary arteries Fenestration | Passive flow to lungs Fenestration shunting | Expected SpO2 Reduced RV workload Lifelong follow up |
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