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Measures of Competence

Clinical competence is comprised of multiple components including skills, attitudes, and knowledge of the cognitive domain. This study focused exclusively on the cognitive aspect of clinical competence. The two measures of cognitive competence used in this study are depicted in Table 1 below. The first of these was norm-referenced data extracted from a standardized exam based on decommissioned NREMT exam items. The second measure of cognitive competence was the achievement exam constructed to measure advanced knowledge. For each of the three cohorts (that is the 2-, 4-, and 6-year cohorts since original registration) Table 1 shows the number of subjects scoring at least 70 percent (70% is required for passing) on the NREMT-based exam. In the year 2 cohort there was no difference in the percent passing the NREMT-based exam; however, there was on the achievement exam. The reregistered cohorts in the 4- and 6-year cohorts performed significantly better than the nonreregistered cohorts on both the NREMT-based and achievement exams.

Table 1. Standardized Exam Scores

Group

N

% Passing NREMT Based Exam

Average
Achievement Score

Year 2 not Rereg

166

68%

13.14

Year 2 Rereg

331

66%

14.09

Year 4 not Rereg

75

59%

12.99

Year 4 Rereg

274

73%

14.40

Year 6 not Rereg

63

60%

13.33

Year 6 Rereg

201

75%

14.54

Because of the categorical nature of the pass/not pass measure, logistic regression was used to test the differences between the reregistered and nonreregistered cohorts for this dependent variable, while analysis of variance was used to test for differences on the achievement test. Table 2 below shows odds ratios for passing the standardized exam between the different cohorts for the achievement test. An odds ratio greater than 1.0 means that the reregistered cohort is more likely than the nonreregistered cohort to have a passing score on the comprehensive portion of the exam.

The data shows that the reregistered cohort did better than the nonreregistered cohorts in years 4 and 6. The years 4 and 6 reregistered cohorts were about twice as likely to pass the NREMT exam than those who did not reregister from the same cohort. The three reregistered cohort groups (on average) were nearly one-and-a-half times as likely to pass the NREMT exam as their nonreregistered counterparts, (although the year 2 non-reregistered group showed no difference in the odds ratio for pass rates and actually did slightly better in mean number of correct scores than the reregistered group).

Table 2. Odds Ratios for Pass Rates for Reregistered and Non Reregistered EMT-Ps

Group

Odds Ratio
reregistered vs. nonreregistered
(95% Confidence Intervals)

p-value

Year 2

0.90 (0.61, 1.35)

0.6221
(NS)

Year 4

1.94 (1.14, 3.30)

0.0146

Year 6

1.99 (1.09, 3.61)

0.0243

Average over all years

1.46 (1.11, 1.90)

0.0061

Table 3 below shows the difference in achievement scores for the reregistered and nonreregistered cohorts. In all cohorts and overall, the reregistered cohorts scored higher than the nonreregistered cohorts. While the score difference was only one question, this was still significant.

Table 3. Achievement Score Differences for Reregistered and Non-reregistered EMT-Ps

Group

Difference
reregistered vs. nonreregistered ¥
(95% Confidence Intervals)

p-value

Year 2

0.95 (0.35, 1.55)

0.0020

Year 4

1.41 (0.59, 2.23)

0.0008

Year 6

1.21 (0.30, 2.12)

0.0094

Average over all years

1.07 (0.66, 1.48)

<0.0001

¥ This is a difference in mean number of correct scores between reregistered and nonreregistered cohorts.

Variables Associated with Reregistration

A question of interest is whether other variables associated with reregistration may account for the some of the differences observed. Data from the demographic questionnaire was considered the most likely source of possible associations with reregistration status. The variables examined for possible associations are shown in Table 4. The c 2 statistic was used to evaluate the statistical difference between the total number of reregistered and non-­reregistered participants. Significant differences were found for several variables. More reregistered EMT-Ps had higher numbers of CMEs since the last State certification and over the 12 months prior to recertification. In addition, reregistered EMT-Ps were more likely to be in States with certification extending 2 years or less and to have a bachelor’s degree or higher. Another difference was the reregistered EMT-Ps had more years of experience.

Table 4: Variables Related to Reregistered and Nonreregistered EMT-Ps

 

Total number of respondents

 

Rereg
(N= 806)

Nonrereg
(N=304)

p-values

Rural area or small town <2500

29.8%

29.6%

0.8449

CME since last State certification more than 60

70.7%

59.2%

0.001

CME over the past 12 months are more than 12

78.5%

69.4%

0.0009

Length of State certification is 2 years or less

56.8%

50.7%

0.0022

20 or more calls in a typical week

45.1%

45.3%

0.1444

Most or all calls are emergency

81.9%

79.6%

0.5411

Highest education bachelor’s or graduate degree

27.2%

22.0%

0.0018

Number of years in EMS

0-4 years
5-10 years
11+ years

 

6.5%
54.6%
39.0%

 

13.3%
52.3%
34.2%

 


<0.0001

Variables Associated with Passing the Standardized Exam

In addition to being tested for their associations with reregistration, the variables identified above were also tested for their association with passing and not passing the NREMT competency exam. These results are shown in Table 5 below. EMT-Ps living in small towns or rural areas were less likely to pass the exam than those living in larger towns. Also, EMT-Ps who passed the exam have more CMEs since last certification as well as over the past 12 months and they have a greater number of calls that are emergency calls. In addition, a greater percentage of those who pass have a bachelor’s or higher degree.

Table 5: Description of Responders Who Passed and Who Did Not Pass the Standardized Exam in Percentages

 

Total number of respondents

 

Pass
(N=765)

Not Pass
(N=345)

P-values

Rural area or small town <2500

26.8%

36.2%

 

CME since last State certification more than 60

70.1%

62.0%

0.0019

CME over the past 12 months are more than 12

79.3%

68.7%

0.0013

Length of State certification is 2 years or less

56.5%

52.2%

0.3207

20 or more calls in a typical week 20 or more

46.4%

39.4%

0.4103

Most or all calls are emergency

83.8%

70.4%

0.0077

Highest education bachelor’s or graduate degree

29.2%

17.7%

0.0023

Number of years in EMS

0-4 years
5-10 years
11+ years

 

11.0%
52.2%
36.0%

 

17.1%
52.2%
30.7%

 


0.7935

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