We aimed to use the consensus opinion of a group of expert emergency physicians to derive a set of emergency diagnoses for acute abdominal pain that might be used as clinically significant outcomes for future research.
We conducted a cross-sectional survey of a convenience sample of emergency physicians with expertise in abdominal pain. These experts were authors of textbook chapters, peer-reviewed original research with a focus on abdominal pain or widely published clinical guidelines. Respondents were asked to categorize 50 possible diagnoses of acute abdominal pain into 1 of 3 categories: 1) unacceptable not to diagnose on the first emergency department (ED) visit; 2) although optimal to diagnose on first visit, failure to diagnose would not be expected to have serious adverse consequences provided the patient had follow-up within the next 2-7 days; 3) if not diagnosed during the first visit, unlikely to cause long-term risk to the patient provided the patient had follow-up within the next 1-2 months. Standard descriptive statistical analysis was used to summarize survey data.
Thirty emergency physicians completed the survey. Of 50 total diagnoses, 16 were categorized as "unacceptable not to diagnose in the ED" with greater than 85% agreement, and 12 were categorized as "acceptable not to diagnose in the ED" with greater than 85% agreement.
Our study identifies a set of abdominal pain conditions considered by expert emergency physicians to be clinically important to diagnose during the initial ED visit. These diseases may be used as "clinically significant" outcomes for future research on abdominal pain.
Under-treatment of pain is frequently reported, especially among seniors, with chronic non-cancer pain most likely to be under-treated. Legislation regarding the prescribing/dispensing of opioid analgesics (including multiple prescription programs [MPP]) may impede access to needed analgesics.
To describe access and intensity of use of analgesics among older Manitobans by health region.
A cross-sectional study of non-Aboriginal non-institutionalized Manitoba residents over 65 years of age during April 1, 2002 to March 31, 2003 was conducted using the Pharmaceutical Claims data and the Cancer Registry from the province of Manitoba. Access to analgesics (users/1000/Yr) and intensity of use (using defined daily dose [DDD] methodology) were calculated for non-opioid analgesics, opioids, and multiple-prescription-program opioids [MPP-opioids]. Usage was categorized by age, gender, and stratified by cancer diagnosis. Age-sex standardized rates of prevalence and intensity are reported for the eleven health regions of Manitoba.
Thirty-four percent of older Manitobans accessed analgesics during the study period. Female gender, increasing age, and a cancer diagnosis were associated with greater access and intensity of use of all classes of analgesics. Age-sex standardized access and intensity measures revealed the highest overall analgesic use in the most rural / remote regions of the province. However, these same regions had the lowest use of opioids, and MPP-opioids among residents lacking a cancer diagnosis.
This population-based study of analgesic use suggests that there may be variations in use of opioids and other analgesics depending on an urban or rural residence. The impact of programs such as the MPP program requires further study to describe its impact on analgesic use.
The incidence of actinic keratosis (AK) is increasing, and several treatment options are available. The aim of this study was to describe clinical characteristics and treatment patterns in patients with AK treated by Danish dermatologists.
A multicenter, non-interventional, cross-sectional study was conducted. Three dermatology hospital departments and seven private dermatology clinics enrolled eligible AK patients consecutively during one week.
A total of 312 patients were included. Non-melanoma skin cancer (NMSC) was previously reported in 51.0% of patients and currently suspected in 9.4% of AK-affected anatomical regions. Lesions of AK were located primarily on the face (38.6%), scalp (12.8%), and hands (11.2%). Actinic keratosis commonly presented with multiple AK lesions (38.6%) and field cancerization (38.5%). The treatments used most frequently were cryotherapy (57.7%) and photodynamic therapy (PDT) with methyl aminolevulinate (17.1%) and imiquimod (11.2%). The likelihood of receiving cryotherapy was higher for men (odds ratio [OR] 1.65, 95% confidence interval [CI] 1.10-2.47) and increased with age (2.2% per year, 0.4-4.0%). PDT represented the most frequently applied treatment for severe actinic damage and was more likely to be prescribed to women (OR 4.08, 95% CI 2.22-7.47) and young patients (OR 0.97 per year, 95% CI 0.95-0.99). The prevalence of severe actinic damage (17.3% versus 9.6%) and intake of immunosuppressive medication (29.0 versus 2.0) were higher among hospital patients compared with those treated in private practices (P
To measure adherence and to identify factors associated with adherence to antihypertensive medications in family practice patients with diabetes mellitus (DM) and hypertension.
A cross-sectional study using a mailed patient self-report survey and clinical data.
Twenty-seven family physician and nurse practitioner clinics from Nova Scotia, New Brunswick, and Prince Edward Island (the Maritime Family Practice Research Network).
A total of 527 patients with type 2 DM and hypertension who had had their blood pressure measured with the BpTRU (an automated oscillometric instrument) at family practice clinic visits within the previous 6 months.
Level of adherence to antihypertension medications as measured by patients' self-report on the Morisky scale; association between high adherence on the Morisky scale and 22 patient factors related to demographic characteristics, clinical variables, knowledge, beliefs, behaviour, health care provider relationships, and health system influences.
The survey response rate was 89.6%. The average age of patients was 66 years, and 51.6% of participants were men. Forty-three percent of patients had had a diagnosis of DM for more than 10 years, and 49.7% had had a diagnosis of hypertension for more than 10 years. Eighty-nine percent of patients had some form of medical insurance. All patients had seen their family physician providers at least once within the past year. Seventy-seven percent of patients reported high adherence as measured by the Morisky scale. On multiple logistic regression, being older than 55, taking more than 7 prescribed medications, and having a lifestyle that included regular exercise or a healthy diet with low salt intake or both were significant independent predictors of high adherence scores on the Morisky scale (P = .05).
More than three-quarters of patients with type 2 DM and hypertension from community family practice clinics in Maritime Canada reported high adherence to their antihypertensive medications. Family physicians and nurse practitioners can apply strategies to improve antihypertensive medication adherence among type 2 DM patients who are younger, taking fewer medications, or not maintaining a lifestyle that includes regular exercise or a healthy diet or both. Future studies will need to determine whether focusing adherence strategies on these patients will improve their cardiovascular outcomes.
To study how prescription patterns concerning respiratory tract infections differ between interns, residents, younger general practitioners (GPs), older GPs and locums.
Retrospective study of structured data from electronic patient records.
Data were obtained from 53 health centres and 3 out-of-hours units in Jönköping County, Sweden, through their common electronic medical record database.
All physicians working in primary care during the 2-year study period (1 November 2010 to 31 October 2012).
Physicians' adherence to current guidelines for respiratory tract infections regarding the use of antibiotics.
We found considerable differences in prescribing patterns between physician categories. The recommended antibiotic, phenoxymethylpenicillin, was more often prescribed by interns, residents and younger GPs, while older GPs and locums to a higher degree prescribed broad-spectrum antibiotics. The greatest differences were seen when the recommendation in guidelines was to refrain from antibiotics, as for acute bronchitis. Interns and residents most often followed guidelines, while compliance in descending order was: young GPs, older GPs and locums. We also noticed that male doctors were somewhat overall more restrictive with antibiotics than female doctors.
In general, primary care doctors followed national guidelines on choice of antibiotics when treating respiratory tract infections in children but to a lesser degree when treating adults. Refraining from antibiotics seems harder. Adherence to national guidelines could be improved, especially for acute bronchitis and pneumonia. This was especially true for older GPs and locums whose prescription patterns were distant from the prevailing guidelines.
The aim was to evaluate the usability of fidelity measures in compliance evaluation of hand hygiene.
Adherence to hand hygiene guidelines is important in terms of patient safety. Compliance measures seldom describe how exactly the guidelines are followed.
A cross-sectional observation study in a university hospital setting was conducted. Direct observation by trained staff was performed using a standardised observation form supplemented by fidelity criteria. A total of 830 occasions were observed in 13 units. Descriptive statistics (frequency, mean, percentages and range) were used as well as compliance rate by using a standard web-based tool. In addition, the binomial standard normal deviate test was conducted for comparing different methods used in evaluation of hand hygiene and in comparison between professional groups.
Measuring fidelity to guidelines was revealed to be useful in uncovering gaps in hand hygiene practices. The main gap related to too short duration of hand rubbing. Thus, although compliance with hand hygiene guidelines measured using a standard web-based tool was satisfactory, the degree of how exactly the guidelines were followed seemed to be critical.
Combining the measurement of fidelity to guidelines with the compliance rate is beneficial in revealing inconsistency between optimal and actual hand hygiene behaviour.
Evaluating fidelity measures is useful in terms of revealing the gaps between optimal and actual performance in hand hygiene. Fidelity measures are suitable in different healthcare contexts and easy to measure according to the relevant indicators of fidelity, such as the length of hand rubbing. Knowing the gap facilitates improvements in clinical practice.
The Healthy Heart Kit (HHK) is a risk management and patient education kit for the prevention of cardiovascular disease (CVD) and the promotion of CV health. There are currently no published data examining predictors of HHK use by physicians. The main objective of this study was to examine the association between physicians' characteristics (socio-demographic, cognitive, and behavioural) and the use of the HHK.
All registered family physicians in Alberta (n=3068) were invited to participate in the "Healthy Heart Kit" Study. Consenting physicians (n=153) received the Kit and were requested to use it for two months. At the end of this period, a questionnaire collected data on the frequency of Kit use by physicians, as well as socio-demographic, cognitive, and behavioural variables pertaining to the physicians.
The questionnaire was returned by 115 physicians (follow-up rate = 75%). On a scale ranging from 0 to 100, the mean score of Kit use was 61 [SD=26]. A multiple linear regression showed that "agreement with the Kit" and the degree of "confidence in using the Kit" was strongly associated with Kit use, explaining 46% of the variability for Kit use. Time since graduation was inversely associated with Kit use, and a trend was observed for smaller practices to be associated with lower use.
Given these findings, future research and practice should explore innovative strategies to gain initial agreement among physicians to employ such clinical tools. Participation of older physicians and solo-practitioners in this process should be emphasized.
To compare triage level assignment, using case scenarios, in a pediatric emergency department between registered nurses (RNs) and pediatric emergency physicians (PEPs) based on the Pediatric Canadian Triage and Acuity Scale (P-CTAS) guidelines. To compare triage level assignment of the RNs and PEPs to that done by a panel of experts using the same P-CTAS guidelines.
A cross-sectional questionnaire survey (55 case scenarios) was sent to all RNs and PEPs working in the emergency department after the P-CTAS was implemented. Participants were instructed to assign a triage level for each case. A priori, all cases were assigned a triage level by a panel of experts using the P-CTAS guidelines. Kappa statistics and the mean number (+/-1SD) of correct responses were calculated.
A response rate of 85% was achieved (29 RNs, 15 PEPs). The kappa level of agreement (95% CI) among RNs was 0.51 (0.50-0.52) and was 0.39 (0.38-0.41) among PEPs (P
To examine the agreement between self-reported and routinely collected administrative health-care utilization data, and the factors associated with agreement between these two data sources.
A representative sample of seniors living in an Ontario county within Canada was identified using the Ontario Ministry of Health's Registered Persons Data Base in 1992. Health professional billing information and hospitalization data were obtained from the Ontario Ministry of Health and Long-Term Care (OMH) and the Ontario Health Insurance Plan (OHIP).
A cross-sectional survey was carried out to assess any contact and frequency of contacts with health professionals and hospital admissions. Similar information was obtained from routinely collected administrative data. The level of agreement was assessed using the proportion of absolute agreement, Cohen's kappa statistic (kappa), and the intraclass correlation coefficient (ICC). Logistic and linear regressions were used to identify factors that were associated with the magnitude and direction of disagreement respectively.
Telephone interviews were conducted on 1,054 seniors, and complete data were available for 1,038 seniors. Each respondent's personal health number was used to electronically link survey data with health professional billing and hospitalization databases.
Substantial to almost perfect agreement was found for the contact utilization measures, while agreement on volume utilization measures varied from poor to almost perfect. In surveys, seniors overreported contact with general practitioners and physiotherapists or chiropractors, and underreported contact with other medical specialists. Seniors also underreported the number of contacts with general practitioners and other medical specialists. The odds of agreement decreased if respondents were male, aged 75 years and older, had incomes of less than $25,000, had poor/fair/good self-assessed health status, or had two or more chronic conditions.
The findings of this study indicate that there are substantial discrepancies between self-reported and administrative data among older adults. Researchers seeking to examine health-care use among older adults need to consider these discrepancies in the interpretation of their results. Failure to recognize these discrepancies between survey and administrative data among older adults may lead to the establishment of inappropriate health-care policies.
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