Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure.

BACKGROUND: The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study. METHODS: General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis. RESULTS: Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees. CONCLUSIONS: Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

[Tiredness/Fatigue-S3 guideline update]. / Müdigkeit ­ Update der S3-Leitlinie.

Background: Fatigue is one of the most common reasons for seeking medical counseling in the family medicine (FM), often entailing diagnostic uncertainty. Patients use terms describing emotional, cognitive, physical, and behavioral aspects. A number of biological, mental, and social causes may underlie the symptom of fatigue, often in combination. This guideline describes the procedures to be applied for primary undetermined symptomatology. Methods: The experts involved conducted a systematic search using the terms for fatigue in the context of FM in PubMed, Cochrane Library and via manual search. Concerning related guidelines, the National Institute for Health and Care Excellence (NICE) guideline was used for myalgic encephalitis/chronic fatigue syndrome (ME/CFS). In a structured consensus process, broad approval of the core recommendations/background text of the revised guideline was attained. Most important messages: 1) Alongside gathering information concerning the symptom characteristics, the anamnesis aims to collect information about pre-existing health conditions, sleeping behavior, use of drugs and psychosocial factors. 2) Depression and anxiety as two common causes will be identified based on screening questions. The occurrence of post-exertional malaise (PEM) will be inquired. 3) The following basic diagnostics are recommended: physical examination, laboratory tests (blood glucose, full blood count, blood sedimentation/CRP, transaminases/γ-GT, TSH). 4) Further examinations should be conducted only in case of specific indications. 5) A biopsychosocial approach is to be adopted. 6) Behavioral therapy and symptom-oriented activating measures can improve fatigue in underlying diseases and undetermined fatigue. 7) In case of PEM, further ME/CFS criteria should be collected and patients have to be supervised accordingly.

Physical activity for chronic back pain: qualitative interview study with patients and GPs in German primary care.

BACKGROUND: Chronic back pain (CBP) is common among patients in primary care and is associated with significant personal and socioeconomic burden. Research has shown that physical activity (PA) is one of the most effective therapies to reduce pain; however, for GPs it remains challenging to advise and encourage individuals with CBP to exercise regularly. AIM: To provide insight into the views and experiences of PA in individuals with CBP, along with those of GPs, and to reveal the facilitators and barriers to engaging in, and maintaining, PA. DESIGN AND SETTING: Qualitative semi-structured interviews with individuals with CBP and GPs recruited via the local research practice network (Famprax) in Hessen, western-central Germany between June and December 2021. METHOD: Interviews were coded separately by consensus and analysed thematically. Findings of the two groups (GPs and patients with CBP) were compared and summarised. RESULTS: A total of 14 patients (n = 9 females and n = 5 males) and 12 GPs (n = 5 females and n = 7 males) were interviewed. Opinions and experiences of PA in individuals with CBP were similar both within and across the GP and patient groups. Interviewees expressed their views on internal and external barriers to PA, and provided strategies to address these barriers and concrete recommendations to increase PA. This study revealed a conflicting doctor-patient relationship ranging from paternalistic, to partnership based, to service provision, which could lead to negative perceptions on both sides, such as frustration and stigma. CONCLUSION: To the best of the authors' knowledge, this is the first qualitative study exploring opinion and experience of PA in individuals with CBP and GPs in parallel. This study reveals a complex doctor- patient relationship and provides an important insight to motivation for, and adherence to, PA in individuals with CBP.

Non-invasive and minimally invasive glucose monitoring devices: a systematic review and meta-analysis on diagnostic accuracy of hypoglycaemia detection.

BACKGROUND: The use of minimally and non-invasive monitoring systems (including continuous glucose monitoring) has increased rapidly over recent years. Up to now, it remains unclear how accurate devices can detect hypoglycaemic episodes. In this systematic review and meta-analysis, we assessed the diagnostic accuracy of minimally and non-invasive hypoglycaemia detection in comparison to capillary or venous blood glucose in patients with type 1 or type 2 diabetes. METHODS: Clinical Trials.gov, Cochrane Library, Embase, PubMed, ProQuest, Scopus and Web of Science were systematically searched. Two authors independently screened the articles, extracted data using a standardised extraction form and assessed methodological quality using a review-tailored quality assessment tool for diagnostic accuracy studies (QUADAS-2). The diagnostic accuracy of hypoglycaemia detection was analysed via meta-analysis using a bivariate random effects model and meta-regression with regard to pre-specified covariates. RESULTS: We identified 3416 nonduplicate articles. Finally, 15 studies with a total of 733 patients were included. Different thresholds for hypoglycaemia detection ranging from 40 to 100 mg/dl were used. Pooled analysis revealed a mean sensitivity of 69.3% [95% CI: 56.8 to 79.4] and a mean specificity of 93.3% [95% CI: 88.2 to 96.3]. Meta-regression analyses showed a better hypoglycaemia detection in studies indicating a higher overall accuracy, whereas year of publication did not significantly influence diagnostic accuracy. An additional analysis shows the absence of evidence for a better performance of the most recent generation of devices. CONCLUSION: Overall, the present data suggest that minimally and non-invasive monitoring systems are not sufficiently accurate for detecting hypoglycaemia in routine use. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2018 CRD42018104812.

Age-based hiring discrimination as a function of equity norms and self-perceived objectivity.

Participants completed a questionnaire priming them to perceive themselves as either objective or biased, either before or after evaluating a young or old job applicant for a position linked to youthful stereotypes. Participants agreed that they were objective and tended to disagree that they were biased. Extending past research, both the objective and bias priming conditions led to an increase in age discrimination compared to the control condition. We also investigated whether equity norms reduced age discrimination, by manipulating the presence or absence of an equity statement reminding decision-makers of the legal prohibitions against discrimination "on the basis of age, disability, national or ethnic origin, race, religion, or sex." The presence of equity norms increased enthusiasm for both young and old applicants when participants were not already primed to think of themselves as objective, but did not reduce age-based hiring discrimination. Equity norms had no effect when individuals thought of themselves as objective - they preferred the younger more than the older job applicant. However, the presence of equity norms did affect individuals' perceptions of which factors were important to their hiring decisions, increasing the perceived importance of applicants' expertise and decreasing the perceived importance of the applicants' age. The results suggest that interventions that rely exclusively on decision-makers' intentions to behave equitably may be ineffective.

Cumulative and career-stage citation impact of social-personality psychology programs and their members.

Number of citations and the h-index are popular metrics for indexing scientific impact. These, and other existing metrics, are strongly related to scientists' seniority. This article introduces complementary indicators that are unrelated to the number of years since PhD. To illustrate cumulative and career-stage approaches for assessing the scientific impact across a discipline, citations for 611 scientists from 97 U.S. and Canadian social psychology programs are amassed and analyzed. Results provide benchmarks for evaluating impact across the career span in psychology and other disciplines with similar citation patterns. Career-stage indicators provide a very different perspective on individual and program impact than cumulative impact, and may predict emerging scientists and programs. Comparing social groups, Whites and men had higher impact than non-Whites and women, respectively. However, average differences in career stage accounted for most of the difference for both groups.

National differences in gender-science stereotypes predict national sex differences in science and math achievement.

About 70% of more than half a million Implicit Association Tests completed by citizens of 34 countries revealed expected implicit stereotypes associating science with males more than with females. We discovered that nation-level implicit stereotypes predicted nation-level sex differences in 8th-grade science and mathematics achievement. Self-reported stereotypes did not provide additional predictive validity of the achievement gap. We suggest that implicit stereotypes and sex differences in science participation and performance are mutually reinforcing, contributing to the persistent gender gap in science engagement.