Abordaje contextual en la práctica del médico de familia / Contextual approach in the practice of the family physician

El contexto representa un conjunto de circunstancias que rodean una situación y, sin las cuales, esta no puede comprenderse en forma correcta. La relación médico paciente está enmarcada en un vínculo contextual. En la práctica cotidiana del médico de familia la atención del paciente se realiza de manera integral, sin disociar el cuerpo del contexto. En este artículo los autores desarrollan el abordaje contextual como herramienta diagnóstica y se describen con detalle dos instrumentos útiles para ponerla en práctica: la evaluación contextual y la entrevista de FOCO (Familia, Orientación y Contexto). (AU)

The context represents a set of circumstances that surround a situation without which it can not be properly understood.The patient-physician relationship is framed in a contextual link. In the daily practice of the family physician, patient careis carried out in an integral manner, without dissociating the body from the context. In this article the authors develop the contextual approach as a diagnostic tool and describe in detail two useful instruments to put it into practice: the contextual assessment and the FOCO interview (Family, Orientation and Context). (AU)

Thyroid cancer under the scope of emerging technologies.

The vast majority of thyroid cancers originate from follicular cells. We outline outstanding issues at each step along the path of cancer patient care, from prevention to post-treatment follow-up and highlight how emerging technologies will help address them in the coming years. Three directions will dominate the coming technological landscape. Genomics will reveal tumoral evolutionary history and shed light on how these cancers arise from the normal epithelium and the genomics alteration driving their progression. Transcriptomics will gain cellular and spatial resolution providing a full account of intra-tumor heterogeneity and opening a window on the microenvironment supporting thyroid tumor growth. Artificial intelligence will set morphological analysis on an objective quantitative ground laying the foundations of a systematic thyroid tumor classification system. It will also integrate into unified representations the molecular and morphological perspectives on thyroid cancer.

Testicular cancer follow-up costs in Germany from 2000 to 2015.

PURPOSE: Advances in testicular cancer screening and therapy increased 10-year survival to 97% despite a rising incidence; eventually expanding the population of survivors requiring follow-up. We analyzed 10-year follow-up costs after testicular cancer treatment in Germany during 2000, 2008, and 2015. METHODS: Testicular cancer follow-up guidelines were extracted from the European Association of Urology. Per patient costs were estimated with a micro-costing approach considering direct and indirect medical expenses derived from expert interviews, literature research, and official scales of tariffs. Three perspectives covering costs for patients, providers, and insurers were included to estimate societal costs. Cost progression was compared across cancer histology, stage, stakeholders, resource use, and follow-up years. RESULTS: Mean 10-year follow-up costs per patient for stage I seminomatous germ-cell tumors (SGCT) on surveillance declined from EUR 11,995 in 2000 to EUR 4,430 in 2015 (p < 0.001). Advanced SGCT spending shrank from EUR 13,866 to EUR 9,724 (p < 0.001). In contrast, expenditure for stage II SGCT increased from EUR 7,159 to EUR 9,724 (p < 0.001). While insurers covered 32% of costs in 2000, only 13% of costs were reimbursed in 2015 (p < 0.001). 70% of SGCT follow-up resources were consumed by medical imaging (x-ray, CT, ultrasound, FDG-PET). Spending was unevenly distributed across follow-up years (years 1-2: 50%, years 3-5: 39%, years 5-10: 11%). CONCLUSIONS: The increasing prevalence of testicular cancer survivors caused German statutory insurers to cut per patient cost by up to 80% by budgeting services and decreasing reimbursement rates. The economic burden was gradually redistributed to patients and providers.

COVID-19 Impact on Vascular Surgery Practice: Experience From an Italian University Regional Hub Center for Vascular Pathology.

BACKGROUND: The aim of the study is to evaluate the impact of COVID-19 pandemic on vascular surgery practice in a regional hub center for complex vascular disease. METHODS: This is an observational single-center study in which we collected clinical and surgical data during (P1) and after (P2) the COVID-19 outbreak and the lockdown measures implemented in Northern Italy. We compared those data with the two-month period before the pandemic (P0). RESULTS: Compared to P0, ambulatory activities were severely reduced during P1 and limited to hospitalized patients and outpatients with urgent criteria. We performed 61 operations (18 urgent and 43 elective), with a decrease in both aortic (-17.8%), cerebrovascular (-53.3%), and peripheral artery (-42.6%) disease treatments. We also observed a greater drop in open procedures (-53.2%) than in endovascular ones (-22%). All the elective patients were treated for notdeferrable conditions and they were COVID-19 negative at the ward admission screening; despite this one of them developed COVID19 during the hospital stay. Four COVID-19 positive patients were treated in urgent setting for acute limb ischemia. Throughout P2 we gradually rescheduled elective ambulatory (+155.5%) and surgical (+18%) activities, while remaining substantially lower than during P0 (respectively -45.6% and -25.7%). CONCLUSIONS: Despite COVID-19 pandemic, our experience shows that with careful patient's selection, dedicated prehospitalization protocol and proper use of personal protective equipment it is possible to guarantee continuity of care.

Longitudinalidade na atenção primária à saúde: revisão integrativa da literatura / Longitudinality in primary health care: an integrative literature review / Longitudinalidad en la atención primaria a la salud: revisión integrativa de la literatura

Objetivo: analisar a produção científica que descreve a longitudinalidade na Atenção Primária à Saúde e verificar como ocorre nos serviços. Método: revisão integrativa da literatura de estudos que tratam sobre a longitudinalidade do cuidado nos serviços. Foram utilizadas as bases de dados Literatura Latino-America e Caribe em Ciências da Saúde, Public MEDLINE, SciVerseScopus e no Portal Regional da Biblioteca Virtual em Saúde utilizando os termos: "Primary Health Care", "Longitudinality" e "Public Health". Resultados: 18 artigos, os quais foram categorizados pela sua similaridade nos temas: estudos sobre os atributos da APS, participação dos usuários na efetivação da longitudinalidade e longitudinalidade no cuidado à criança. Conclusão: a confiança mútua entre profissionais e usuários, a continuidade da atenção, a escuta, a credibilidade e a vinculação do usuário com os profissionais configuram a longitudinalidade nos serviços de saúde

Objective:To analyze the scientific production that describes longitudinality in Primary Health Care and to verify how it occurs in the services. Method: integrative review of the literature of studies that deal with the longitudinality of care in services. The Latin American and Caribbean Literature in Health Sciences, Public Medline, SciVerseScopus and the Regional Portal of the Virtual Health Library were used using the terms "Primary Health Care", "Longitudinality" and "Public Health". Results: 18 articles, which were categorized by their similarity in the themes: studies on the attributes of APS, participation of users in the effectiveness of longitudinality and longitudinality in child care. Conclusion: mutual trust between professionals and users, continuity of attention, listening, credibility and the link between the user and the professionals configures longitudinality in health services

Objetivo: Analizar la producción científica que describe la longitudinalidad en la Atención Primaria a la Salud y verificar cómo ocurre en los servicios. Método: revisión integrativa de la literatura de estudios que tratan sobre la longitudinalidad del cuidado en los servicios. Se utilizaron las bases de datos Literatura Latinoamérica y Caribe en Ciencias de la Salud, Public Medline, SciVerseScopus y en el Portal Regional de la Biblioteca Virtual en Salud utilizando los términos: "Primary Health Care", "Longitudinality" y "Public Health". Resultados: 18 artículos, los cuales fueron categorizados por su similitud en los temas: estudios sobre los atributos de la APS, par-ticipación de los usuarios en la efectividad de la longitudinalidad y longitudinalidad en el cuidado al niño. Conclusión: la confianza mutua entre profesionales y usuarios, la continuidad de la atención, la escucha, la credibilidad y la vinculación del usuario con los profesionales configuran la longitudinalidad en los servicios de salud

Cuidado à pessoa com insuficiência cardíaca após alta hospitalar: revisão integrativa / Care for people with heart failure after hospital discharge: integrative review / Cuidado de personas con insuficiencia cardiaca después del alta del paciente: revisión integrativa

Objetivo: Identificar as evidências acerca das orientações que devem ser oferecidas à pessoa com Insuficiência Cardíaca para a continuidade do tratamento. Método: Revisão integrativa, com busca nas bases de dados Lilacs, Pubmed, Cinahl, Web of Science e Scopus. Resultados: Dos 5422 títulos identificados, 31 artigos foram incluídos para análise. Apreendeu-se que os estudos abordaram, dentre outros aspectos, a importância da orientação da doença, dos sinais e sintomas e da detecção da agudização; no entanto, constatou-se a dificuldade na utilização de linguagem adequada para facilitar a compreensão pela pessoa e/ou pelos familiares. Conclusão: Sugere-se que mais estudos sejam realizados a respeito desse tema, a fim de possibilitar aos profissionais de saúde a formulação de um plano de cuidados coerente, com fundamentação nas melhores evidências científicas

Objective: to identify the evidence on the guidance that should be offered to people with heart failure to continue treatment. Method:integrative review, searching the databases Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), National Library of Medicine (PUBMED/MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science e Scopus. Results: of the 5422 titles identified, 32 articles were included for analysis. It was understood that the studies addressed, among other aspects, the importance of disease orientation, signs and symptoms, and acute detection; however, it was found that it was difficult to use adequate language to facilitate understanding by the person and/or family members. Conclusion: it is suggested that more studies be conducted on this topic, in order to enable health professionals to formulate a coherent care plan, based on the best scientific evidence

Objetivo: identificar la evidencia sobre las pautas que deberían ofrecerse a las personas con insuficiencia cardíaca para continuar el tratamiento. Método: revisión integrativa, búsqueda en las bases de datos Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), National Library of Medicine (PUBMED/MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science e Scopus.Resultados: de los 5422 títulos identificados, se incluyeron 32 artículos para su análisis. Se entendió que los estudios abordaron, entre otros aspectos, la importancia de la orientación de la enfermedad, los signos y síntomas, y la detección aguda; sin embargo, se descubrió que era difícil usar un lenguaje adecuada para facilitar la comprensión por parte de la persona y/o miembros de la familia. Conclusión: Se sugiere que se realicen más estudios sobre este tema, a fin de permitir a los profesionales de la salud formular un plan de atención coherente, basado en la mejor evidencia científica

Continuidad del cuidado / Continuity of care

El concepto de continuidad del cuidado (CoC) suele utilizarse para describir en qué medida los pacientes ven al mismo profesional a lo largo del tiempo, aunque más específicamente es un atributo o característica del proceso de atención de salud de un individuo en el que la calidad de la conexión y retroalimentación de los eventos que se suceden influyen en la experiencia final de sentirse cuidado. La CoC abarca diferentes dominios conceptuales: la continuidad de la información, de la relación y del manejo. Se han utilizado diferentes instrumentos de medición que pueden agruparse en herramientas elaboradas a partir de reportes de pacientes (como por ej., encuestas) o a partir de datos administrativos (como los indicadores de prestador usual de cuidados o el indicador de Bice y Boxerman). Existen también investigaciones que evaluaron el impacto sanitario de la CoC. Si bien muchas de ellas muestran gran heterogeneidad en cuanto a los indicadores y los desenlaces utilizados, se observa una tendencia clara que parece indicar que a mayor nivel de continuidad del cuidado, mejores resultados en salud. (AU)

The concept of continuity of care (CoC) is often used to describe the extent to which patients see the same professional over time, but more specifically it is an attribute or characteristic of an individual's health care process in which the quality of the connection and feedback of the events that follow influences the final experience of feeling cared for. CoC encompasses different conceptual domains: continuity of information, relationship, and management. Different measurement instruments have been used, which can be grouped into tools developed from patient reports (e.g. surveys) or from administrative data (e.g. usual caregiver indicators or the Bice & Boxerman indicator). There is also research that has assessed the health impact of CoC. While many of them show great heterogeneity in terms of the indicators and outcomes used, there is a clear trend that seems to indicate that the higher the level of continuity ofcare, the better the health outcomes. (AU)

Trends of Follow-Up Recommendations Made on Musculoskeletal MRI Reports.

OBJECTIVE. The purpose of this article was to analyze trends in follow-up recommendations made on musculoskeletal MRI reports. MATERIALS AND METHODS. An IRB-approved retrospective study identified 790 musculoskeletal MRI reports from our database between January 1, 2016, and January 1, 2018, containing follow-up recommendations made by the interpreting radiologist. Metadata were automatically extracted and classification of the recommendations was performed by manual review. Clinical outcome data were collected from the electronic health record. After exclusion criteria were applied, 654 reports were included in the study. Descriptive statistics, Fisher exact tests, and chi-square tests were used for analysis. RESULTS. Clinicians acknowledged 83% and followed 73% of the recommendations. Follow-up compliance varied with the type of recommendation made: 98% for clinical intervention versus 67% for additional imaging (p < 0.001). Subspecialties acknowledged and followed recommendations at different rates: 92% and 85% for internists versus 76% and 64% for orthopedists (p < 0.001 and p < 0.001), respectively. Patient age, practice setting, radiologist experience, recommendation conditionality, and specified follow-up time intervals made no difference in compliance rate (all p > 0.05). There was no difference in compliance rate among various pathologic findings of concern (p = 0.995). Compliance rate increased significantly after direct communication between the radiologist and clinician compared with when there was no direct communication (93% vs 71%, p < 0.001). Concern for neoplasm comprised the greatest number of unacknowledged recommendations (73%). CONCLUSION. Musculoskeletal MRI recommendations are followed independent of the finding of concern and compliance is lowest for requests of additional imaging. Direct communication improves compliance and may be particularly helpful for orthopedic referrers.

Impact of Survivorship Care Plans and Planning on Breast, Colon, and Prostate Cancer Survivors in a Community Oncology Practice.

With a growing number of cancer survivors, survivorship care plans (SCPs) are recommended to communicate information about late effects of treatment and follow-up care. Community oncology practices follow 85% of adult cancer survivors but report more difficulty in providing SCPs compared to academic centers. Our objective was to evaluate the impact of delivering SCPs in a community oncology practice by examining awareness of SCP receipt as well as how provision affects survivors' perception of care quality and of their condition. Survivors who accepted a SCP as standard of care were recruited from a community oncology practice in the Midwest and completed surveys prior to SCP provision (baseline) and 4 weeks later (follow-up). Within-survivor changes in knowledge of SCP receipt, satisfaction and perceived care coordination were assessed. Thirty cancer survivors (breast, colon, and prostate) completed the baseline survey, while 24 completed the follow-up survey (80% response rate). Participants reported receiving SCPs and treatment summaries more frequently at follow-up after receiving a SCP. At follow-up, there was a significant increase in survivor activation and involvement in care along with satisfaction of knowledge of care. Communication about and during SCP provision may need to be clearer: 34% of survivors could not correctly identify SCP receipt in this study. This may place these survivors at a disadvantage, if this leads to less awareness of important information regarding follow-up surveillance and management. Of those aware of SCP receipt, SCP provision had positive impacts in this small, short-term study.

Salud digital: una estrategia de continuidad asistencial para personas con enfermedades no transmisibles durante la COVID-19 / Digital Health: a strategy to maintain health care for people living with noncommunicable diseases during COVID-19 / Saúde Digital: uma estratégia para manter a assistência à saúde de pessoas que vivem com doenças não transmissíveis durante a pandemia de COVID-19

Las enfermedades no transmisibles (ENT) son la primera causa de muerte y discapacidad en el mundo. El tratamiento eficaz de estos trastornos crónicos depende en gran medida de la continuidad de unos servicios receptivos, accesibles y de calidad, así como de la participación de los pacientes y su autocuidado. Está comprobado que la salud digital ­en particular la telemedicina y las historias clínicas y recetas electrónicas­ es ventajosa para resguardar la continuidad de la atención, especialmente cuando hay alteraciones de los servicios, además de facilitar el seguimiento y evaluación de las intervenciones contra las ENT

Noncommunicable diseases (NCDs) are the main cause of death and disability worldwide. Effective management of these chronic conditions depends largely on continuous, responsive, accessible, and quality services and successful patient engagement and self-management. Digital health, and in particular telemedicine visits, electronic records, and electronic prescriptions, have already demonstrated having advantages in successfully ensuring continuity of care, especially when services are disrupted, as well as monitoring and evaluating interventions for NCDs

As doenças não transmissíveis (DNTs) são a principal causa de morte e incapacidade em todo o mundo. O controle eficaz dessas doenças crônicas depende em grande parte de serviços continuados, responsivos, acessíveis e de qualidade, além de engajamento e autocontrole satisfatórios por parte dos pacientes. A saúde digital, em especial as teleconsultas médicas, os prontuários eletrônicos e as prescrições eletrônicas, já demonstrou ser vantajosa para assegurar a continuidade da assistência, principalmente quando os serviços são interrompidos, além do monitoramento e da avaliação de intervenções em DNTs

Of Slide Rules and Stethoscopes: AI and the Future of Doctoring.

Historically, the practice of medicine has been a physically intimate endeavor. Physicians have used their hands to palpate and reveal the secrets hidden within the body. Smelling the breath for the ketosis of diabetes or tasting the skin for the saltiness of cystic fibrosis were among the physician's essential practices. Today, perhaps the most defining characteristic of a brilliant clinician is the ability to synthesize many images-from electrocardiograms, ultrasounds, CT scans, and so forth-into a coherent picture that can guide our diagnosis and treatment. Yet this is rapidly becoming a Sisyphean task. Just as we are about to drown in a deluge of data, AI is throwing us a life preserver, to save not only our patients but ourselves. But where will AI take us?

Impact of Adding Telephone-Based Care Coordination to Standard Telephone-Based Smoking Cessation Counseling Post-hospital Discharge: a Randomized Controlled Trial.

BACKGROUND: Cessation counseling and pharmacotherapy are recommended for hospitalized smokers, but better coordination between cessation counselors and providers might improve utilization of pharmacotherapy and enhance smoking cessation. OBJECTIVE: To compare smoking cessation counseling combined with care coordination post-hospitalization to counseling alone on uptake of pharmacotherapy and smoking cessation. DESIGN: Unblinded, randomized clinical trial PARTICIPANTS: Hospitalized smokers referred from primarily rural hospitals INTERVENTIONS: Counseling only (C) consisted of telephone counseling provided during the hospitalization and post-discharge. Counseling with care coordination (CCC) provided similar counseling supplemented by feedback to the smoker's health care team and help for the smoker in obtaining pharmacotherapy. At 6 months post-hospitalization, persistent smokers were re-engaged with either CCC or C. MAIN MEASURES: Utilization of pharmacotherapy and smoking cessation at 3, 6, and 12 months post-discharge. KEY RESULTS: Among 606 smokers randomized, 429 (70.8%) completed the 12-month assessment and 580 (95.7%) were included in the primary analysis. Use of any cessation pharmacotherapy between 0 and 6 months (55.2%) and between 6 and 12 months (47.1%) post-discharge was similar across treatment arms though use of prescription-only pharmacotherapy between months 6-12 was significantly higher in the CCC group (30.1%) compared with the C group (18.6%) (RR, 1.61 (95% CI, 1.08, 2.41)). Self-reported abstinence rates of 26.2%, 20.3%, and 23.4% at months 3, 6, and 12, respectively, were comparable across the two treatment arms. Of those smoking at month 6, 12.5% reported abstinence at month 12. Validated smoking cessation at 12 months was 19.3% versus 16.9% in the CCC and C groups, respectively (RR, 1.13 (95% CI, 0.80, 1.61)). CONCLUSION: Supplemental care coordination, provided by counselors outside of the health care team, failed to improve smoking cessation beyond that achieved by cessation counseling alone. Re-engagement of smokers 6 months post-discharge can lead to new quitters, at which time care coordination might facilitate use of prescription medications. TRIAL REGISTRATION: NCT01063972.

Table in the corner: a qualitative study of life situation and perspectives of the everyday lives of oesophageal cancer patients in palliative care.

BACKGROUND: Incurable oesophageal cancer patients are often affected by existential distress and deterioration of quality of life. Knowledge about the life situation of this patient group is important to provide relevant palliative care and support. The purpose of this study is to illuminate the ways in which incurable oesophageal cancer disrupts the patients' lives and how the patients experience and adapt to life with the disease. METHODS: Seventeen patients receiving palliative care for oesophageal cancer were interviewed 1-23 months after diagnosis. The epistemological approach was inspired by phenomenology and hermeneutics, and the method of data collection, analysis and interpretation consisted of individual qualitative interviews and meaning condensation, inspired by Kvale and Brinkmann. RESULTS: The study reveals how patients with incurable oesophageal cancer experience metaphorically to end up at a "table in the corner". The patients experience loss of dignity, identity and community. The study illuminated how illness and symptoms impact and control daily life and social relations, described under these subheadings: "sense of isolation"; "being in a zombie-like state"; "one day at a time"; and "at sea". Patients feel alone with the threat to their lives and everyday existence; they feel isolated due to the inhibiting symptoms of their illness, anxiety, worry and daily losses and challenges. CONCLUSIONS: The patients' lives are turned upside down, and they experience loss of health, function and familiar, daily habits. The prominent issues for the patients are loneliness and lack of continuity. As far as their normal everyday lives, social networks and the health system are concerned, patients feel they have been banished to a "table in the corner". These patients have a particular need for healthcare professionals who are dedicated to identifying what can be done to support the patients in their everyday lives, preserve dignity and provide additional palliative care.

The continuum of critical care.

Until relatively recently, critical illness was considered as a separate entity and the intensive care unit (ICU), often a little cut-off from other areas of the hospital, was in many cases used as a last resort for patients so severely ill that it was no longer possible to care for them on the general ward. However, we are increasingly realizing that critical illness should be seen as just one part of the patient's disease trajectory and how the patient is managed before and after ICU admission has an important role to play in optimizing outcomes. Identifying critical illness early, before it reaches a stage where it is life-threatening, is a challenge and requires a combination of improved and more frequent or continuous monitoring of at-risk patients, staff training to recognize when a patient is deteriorating, a system to "call for help," and an effective response to that call. Critical care doctors are now widely available 24 h a day for consultation, and many hospitals have rapid response or medical emergency teams composed of staff trained in intensive care and with resuscitation skills who can attend patients on the ward who have been identified to be deteriorating, assess them to determine the need for ICU admission, and initiate further tests and/or initial therapy. Early intensivist input may also be important for patients undergoing interventions that are likely to result in ICU admission, e.g., transplantation or cardiac surgery. The patient's continuum after ICU discharge must also be taken into account during their ICU stay, with attempts made to limit the longer-term physical and psychological consequences of critical illness as much as possible. Minimal sedation, good communication, and early mobilization are three factors that can help patients survive their ICU stay with minimal sequelae.

Where Have We Been, Where Are We Going: Continuity from 2011.

This article provides a brief review of important foundational concepts and an overview of major milestones in the history of animal hospice and palliative care. This article also presents a view of future goals and challenges that lie ahead of the veterinary profession as the field of animal hospice and palliative care evolves. Some examples of topics reviewed and explored in the article include current "state of-the-art" of animal hospice, future research goals, improved veterinary college curricula, collaboration among medical disciplines, and support of the veterinary staff.

Hepatitis C continuum of care and utilization of healthcare and harm reduction services among persons who inject drugs in Seattle.

BACKGROUND: To describe the "continuum of care" for hepatitis C virus (HCV) and related health service utilization among persons who inject drugs (PWID) in the Seattle metropolitan area. METHODS: The study analyzed data from the 2015 National HIV Behavioral Surveillance system focused on PWID, which included local questions on HCV treatment and testing. We calculated respondent driven sampling (RDS)-adjusted percentages of participants who had completed each step of the care continuum and compared healthcare harm reduction services among participants who were HCV + vs. HCV- using bivariate analyses. RESULTS: 513 PWID were screened for HCV antibodies (Ab). Of those, 59.7% were HCV Ab+. Among those HCV Ab+, 86.4% had been tested for HCV at least once; 69.9% reported a previous diagnosis. Of those diagnosed, 55.9% had received a confirmatory test, 17.2% had ever received any medications for HCV, and 7.2% had completed treatment. The majority of HCV Ab + participants had seen a health care provider in the past 12 months (85.6%). CONCLUSIONS: There is a large gap between HCV screening and treatment among Seattle area PWID.

The Impact of a Primary Care Education Program Regarding Cancer Survivorship Care Plans: Results from an Engineering, Primary Care, and Oncology Collaborative for Survivorship Health.

Survivorship care plans (SCPs) have been recommended as tools to improve care coordination and outcomes for cancer survivors. SCPs are increasingly being provided to survivors and their primary care providers. However, most primary care providers remain unaware of SCPs, limiting their potential benefit. Best practices for educating primary care providers regarding SCP existence and content are needed. We developed an education program to inform primary care providers of the existence, content, and potential uses for SCPs. The education program consisted of a 15-min presentation highlighting SCP basics presented at mandatory primary care faculty meetings. An anonymous survey was electronically administered via email (n = 287 addresses) to evaluate experience with and basic knowledge of SCPs pre- and post-education. A total of 101 primary care advanced practice providers (APPs) and physicians (35% response rate) completed the baseline survey with only 23% reporting prior receipt of a SCP. Only 9% could identify the SCP location within the electronic health record (EHR). Following the education program, primary care physicians and APPs demonstrated a significant improvement in SCP knowledge, including improvement in their ability to locate one within the EHR (9 vs 59%, p < 0.0001). A brief educational program containing information about SCP existence, content, and location in the EHR increased primary care physician and APP knowledge in these areas, which are prerequisites for using SCP in clinical practice.

Advanced care planning in adult congenital heart disease: Transitioning from repair to palliation and end-of-life care.

As a result of advances in pediatric care, the majority of patients born with congenital heart disease (CHD) survive into adulthood [1]. Effective transfer and transition programs assure that patients with CHD remain in follow-up and receive continuous holistic care. Unfortunately, adult patients with CHD carry residual lesions and sequelae putting them at risk for premature death related to re-interventions or complications; most commonly heart failure and arrhythmia [2]. The scientific adult CHD (ACHD) community has been working hard to identify variables related to worse outcomes, modifying those where possible in order to improve survival. Indeed, survival in adults with CHD has increased, but consequently, on top of CHD-related complications, patients are increasingly exposed to the standard cardiovascular risk factors. Therefore, a program for lifelong coaching on health behavior and life style management becomes indispensable. More emerging is that a substantial number of patients, in particular those with complex heart defects, will eventually end up in a stage with hardly any medical or interventional options left. Our healthcare provision has to be prepared to organize care for this specific group of patients who will die prematurely and require the timely development and establishment of advanced care planning. Advanced care planning should preferentially be set-up in expert CHD centers. The long-lasting relationship in ACHD care with healthcare providers offers an excellent basis with regards to prognosis, advanced care planning and end-of-life issues.

"Do You Know What I Know?": How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs.

BACKGROUND: Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks. OBJECTIVES: We investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients. METHODS/PARTICIPANTS: We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs). MAIN MEASURES: We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews. KEY RESULTS: The effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed. CONCLUSIONS: We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.