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OBJECTIVES: This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the effectiveness of telemedicine diabetic retinopathy screening versus traditional in-person eye exams in people with type 1 or 2 diabetes mellitus on screening uptake, screening adherence, and referral adherence.
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Retinopatia Diabética , Programas de Rastreamento , Telemedicina , Humanos , Retinopatia Diabética/diagnóstico , Programas de Rastreamento/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Encaminhamento e Consulta/estatística & dados numéricos , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 1/complicaçõesRESUMO
Ophthalmology is undergoing rapid transformation through the integration of smart technologies such as artificial intelligence (AI), big data analytics, and clinical decision support systems (CDSS). With increasing pressure to improve clinical efficiency and manage growing patient volumes, the potential for smart technologies to streamline ophthalmic care warrants more exploration. To date, smart technologies have demonstrated potential as practical adjunctive tools that support ophthalmic referrals and clinical practice in ophthalmology. Smart technologies that support ophthalmic referrals now include CDSS that contain algorithms with the capacity to more efficiently identify suspected ophthalmic diseases that may be urgent or require prompt treatment in the primary care setting, compared with traditional referral models. These approaches also include installation of AI-powered ophthalmic imaging machines and electronic health records-analytical packages in primary care offices, where they can be used to screen for structural, historical, or symptomatic manifestations of ophthalmic diseases requiring ophthalmologist evaluation. Meanwhile, smart technologies that support ophthalmology practices include AI and big data simulations for optimized patient encounter schedules and chatbot-facilitated appointment confirmations. Amidst a smart technology renaissance, review is needed to capture existing smart technologies to inform integration in the practices of ophthalmic and general practitioners. This article aims to review the clinical utility of emerging smart technology relevant to ophthalmic referrals and ophthalmology practice.
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Inteligência Artificial , Big Data , Oftalmologia , Encaminhamento e Consulta , Humanos , Inteligência Artificial/tendências , Oftalmologia/métodos , Oftalmologia/tendências , Encaminhamento e Consulta/tendências , Sistemas de Apoio a Decisões Clínicas , Oftalmopatias/diagnóstico , Registros Eletrônicos de Saúde , AlgoritmosRESUMO
Introduction: The screening, brief intervention, and referral to treatment (SBIRT) approach is an evidence-based tool that combines standardized screening for unhealthy or risky alcohol and drug use with principles of motivational interviewing to promote behavior change and connect patients with the appropriate treatment and recovery support services. There is an increased demand for health care students and providers to be trained in SBIRT. We developed a curriculum to improve medical students' attitudes toward and proficiency in administering SBIRT. Methods: The curriculum was deployed as part of the emergency department clerkship of an undergraduate medical education program at an urban, safety net academic medical center. The content and structure, developed with input from medicine, nursing, and social work educators, consists of a 1-hour didactic session, three rounds of formative OSCE encounters, and one SBIRT delivery in the emergency department. Students were evaluated on their attitudes, sense of preparedness, and practical understanding of SBIRT. Results: Fifty-six medical students participated in the curriculum. There were significant differences between students' pre- and postcurriculum attitudes and preparedness scores (p < .001) and knowledge scores (p = .002), and in OSCE scores between the first and third standardized patient encounter (p = .03). Discussion: This curriculum significantly impacted medical students' attitudes and knowledge regarding SBIRT and motivational interviewing techniques. Widespread implementation of similar curricula could equip future physicians with the skills to implement evidence-based substance use screening and intervention into their practice.
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Programas de Rastreamento , Estudantes de Medicina , Humanos , Currículo/tendências , Encaminhamento e Consulta/tendências , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudantes de Medicina/psicologia , Estudantes de Medicina/estatística & dados numéricos , Programas de Rastreamento/métodos , Educação de Graduação em Medicina/métodos , Entrevista Motivacional/métodos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/terapia , Feminino , Masculino , Adulto , Estágio Clínico/métodos , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Venous thromboembolism (VTE) is labeled as an adverse effect of the adeno-vector-based vaccines AstraZeneca and Johnson & Johnson. We aimed to study whether there was an increase in general practitioner (GP) consultations for VTE after COVID-19 vaccination. METHODS: An exposure-anchored self-controlled cohort study was performed among COVID-19 vaccinated persons aged ≥ 12 years who were registered in the PHARMO Data Network and Nivel Primary Care Database in the Netherlands. The focal window was set at 28 days after each COVID-19 vaccination and the referent window at all time outside the focal window. Adjusted incidence rate ratios (aIRR), adjusting for SARS-CoV-2 infection, were calculated using Poisson regression. RESULTS: In total, 2 133 853 persons were included. The highest increase in GP consultations for VTE was observed after Johnson & Johnson vaccination (aIRR: 3.14, 95% CI: 1.50-6.57), and a slight increase after Pfizer/BioNTech dose 1 (aIRR: 1.24, 95% CI: 1.09-1.40). Risk groups were 12-60 year-olds with increased GP consultations for VTE after Johnson & Johnson (aIRR: 2.30, 95% CI: 1.44-3.69) and Pfizer/BioNTech (aIRR: 1.29, 95% CI: 1.11-1.50), and in specific groups of males aged 12-60 years. Also, females using hormone-containing contraceptives or hormone replacement therapy (HRT) showed increased GP consultations for VTE after AstraZeneca (aIRR: 2.87, 95% CI: 1.13-7.33) and Pfizer/BioNTech (aIRR: 1.48, 95% CI: 1.10-2.01). CONCLUSION: Increased GP consultations for VTE were observed after both vector and mRNA vaccination, in particular among males, 12-60 year olds, and females using hormone-containing contraceptives or HRT.
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Vacinas contra COVID-19 , COVID-19 , Clínicos Gerais , Atenção Primária à Saúde , Encaminhamento e Consulta , Tromboembolia Venosa , Humanos , Feminino , Masculino , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/induzido quimicamente , Tromboembolia Venosa/diagnóstico , Países Baixos/epidemiologia , Pessoa de Meia-Idade , Adulto , Atenção Primária à Saúde/estatística & dados numéricos , Vacinas contra COVID-19/efeitos adversos , Vacinas contra COVID-19/administração & dosagem , Adolescente , Idoso , Estudos de Coortes , Adulto Jovem , Criança , Encaminhamento e Consulta/estatística & dados numéricos , COVID-19/prevenção & controle , Vacinação/efeitos adversos , Vacina BNT162 , Clínicos Gerais/estatística & dados numéricosRESUMO
PURPOSE: Beyond standardized screenings, clinical assessments by psycho-oncologists during initial consultations play a key role in guiding psychosocial cancer care. Despite their relevance, these assessments have rarely been systematically examined. The aim of this study was to analyze psycho-oncologists' assessments of psychological distress and support needs and to identify factors influencing their assessments. METHODS: In a cross-sectional study, N = 9 psycho-oncologists retrospectively evaluated N = 1048 initial psychooncological consultations. The perceived psychological distress, depression, anxiety, health literacy and support needs of patients were recorded, as well as consultation-related conditions and the psycho-oncologists' own stress levels. Analyses involved descriptive statistics, group comparisons, correlations, and a binomial logistic regression. RESULTS: A distress score ≥ 5 was observed by psychooncologists in 74.7% of patients; 44.5% were rated as anxious, 28.6% as depressed. Mental health diagnoses were made in 25% of cases, mainly adjustment or affective disorders. Psycho-oncological support needs were identified in 75.6% of patients. Key predictors for identifying distress and needs included patients' desire for support (OR = 45.06), Knowledge and information about the consultation (OR = 2.66), and psycho-oncologists' own stress levels (OR = 1.53). CONCLUSION: Psycho-oncological initial assessments are clinically relevant, but are subject to contextual and personal influences. The structured collection of consultation requests, information awareness, and health literacy, as well as interdisciplinary collaboration, can improve the assessment. The psychological stress of psycho-oncologists should also be systematically taken into account.
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Neoplasias , Oncologistas , Psico-Oncologia , Angústia Psicológica , Estresse Psicológico , Humanos , Feminino , Masculino , Estudos Transversais , Pessoa de Meia-Idade , Neoplasias/psicologia , Neoplasias/terapia , Adulto , Estresse Psicológico/diagnóstico , Estresse Psicológico/psicologia , Estudos Retrospectivos , Idoso , Oncologistas/psicologia , Encaminhamento e Consulta , Avaliação das Necessidades , Ansiedade/psicologia , Ansiedade/diagnóstico , Depressão/psicologia , Depressão/diagnósticoRESUMO
BACKGROUND: Human Immunodeficiency Virus (HIV) remains a major global health challenge, particularly in sub-Saharan Africa. It is a multisystem disorder with significant renal involvement. In Ethiopia, limited data exist on the prevalence of impaired estimated glomerular filtration rate among patients with Human Immunodeficiency Virus. Identifying associated factors is critical for implementing targeted interventions to preserve renal function. METHODS: An institution-based cross-sectional study was conducted among 252 adult patients living with Human Immunodeficiency Virus from October 1 to December 30, 2024 at Asella Referral and Teaching Hospital. Data were collected via structured questionnaires and medical record reviews. Bivariate and multivariate logistic regression analyses were performed to identify factors associated with impaired glomerular filtration rate (estimated glomerular filtration rate <60 mL/min/1.73m2). RESULT: The prevalence of impaired glomerular filtration rate was 18.7% (95% CI: 14.0-23.0). Factors significantly associated with impaired glomerular filtration rate included age > 40 years (AOR = 3.26; 95%CI: 1.17-9.12), history of smoking (AOR = 4.68; 95% CI: 1.87-11.70), opportunistic infections (AOR = 5.93; 95% CI: 2.23-15.74), diabetes mellitus (AOR = 3.86; 95% CI: 1.47-10.12) and hypertension (AOR = 2.71; CI: 1.07-6.82). CONCLUSION: The study found that around 19% of the studied population had impaired glomerular filtration rate. Targeted screening for kidney disease should focus on individuals older than 40years, smokers and those with opportunistic infections, diabetes mellitus or hypertension.
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Taxa de Filtração Glomerular , Infecções por HIV , Humanos , Adulto , Masculino , Etiópia/epidemiologia , Feminino , Estudos Transversais , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Infecções por HIV/fisiopatologia , Pessoa de Meia-Idade , Hospitais de Ensino , Fatores de Risco , Prevalência , Encaminhamento e Consulta , Adulto JovemRESUMO
Dental clearance prior to radiotherapy (RT) can extend pretreatment timelines in head and neck cancer (HNC). However, its specific contribution to delays is rarely quantified, and no timing benchmarks exist for patients treated with RT without prior surgery. We conducted a retrospective descriptive study at a Canadian tertiary center, including all adults referred for pre-RT dental evaluation between January 1 and December 31, 2022. Delay metrics were defined as days from consultation to surgery, surgery to clearance, and consultation to RT start. Analyses were descriptive, with complete-case calculations. Among 463 patients scheduled for RT, 356 dentate or partially dentate individuals were referred for dental assessment. Of these, 29 (8.2%) required extended healing or multiple follow-ups. Median consultation-to-surgery delay was 6 days (range 0-31), surgery-to-clearance 22 days [8-119], and consultation-to-RT 28 days [15-133]. Six patients (20.7%) experienced delays extending beyond a 42-day period, used here as a contextual benchmark for exploratory comparison rather than as a formal standard. Follow-up was inadequate in 15/29 (51.7%). One patient (3.4%) developed osteoradionecrosis. This study provides the first descriptive quantification of dental clearance-related delays on RT-only patients in a Canadian tertiary center. Although most achieved clearance within expected timelines, a minority experienced clinically meaningful delays linked to prolonged healing and inadequate follow-up, highlighting dental clearance as a modifiable bottleneck in pretreatment planning and supporting the need for standardized reassessment intervals, structured recall systems, and improved cross-disciplinary coordination. Future multicenter studies are warranted to establish operational benchmarks and evaluate targeted quality-improvement strategies.
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Neoplasias de Cabeça e Pescoço , Tempo para o Tratamento , Extração Dentária , Humanos , Estudos Retrospectivos , Masculino , Feminino , Centros de Atenção Terciária , Neoplasias de Cabeça e Pescoço/radioterapia , Neoplasias de Cabeça e Pescoço/cirurgia , Pessoa de Meia-Idade , Canadá , Idoso , Adulto , Idoso de 80 Anos ou mais , Fatores de Tempo , Encaminhamento e ConsultaRESUMO
BACKGROUND: Identifying diagnoses from noncoded healthcare visit records presents logistical challenges when large number of records are screened. This study aimed to develop a screening process to identify otitis media (OM) diagnoses in free-text primary care visit records. METHODS: The free-text primary care records of 200 children aged 0 to 4 years were reviewed independently by three clinicians to determine whether OM was a diagnosis considered during each visit. Terms (abbreviations, words, and phrases) identifying visits where OM was considered or excluded were documented. These terms were used to design a software algorithm subsequently used to detect OM diagnosis within these primary care records. The diagnostic performance of the software algorithm was determined against the gold standard clinicians' review and described using sensitivity, specificity, predictive values (PVs), and likelihood ratios (LRs) with 95% confidence intervals (CIs). RESULTS: The 200 children had 10,034 primary care visits. Clinician review identified 917 (9%) visits where OM was considered, and 9117 (91%) visits where OM was excluded. The software algorithm identified 801/917 visits where OM was considered and 8705/9117 visits where OM was excluded. The algorithm sensitivity was 87% (95% CI 85-89), specificity 96% (95% CI 95-96), positive PV 66% (95% CI 63-69), negative PV 99% (95% CI 98-99), positive LR 19.33 (95% CI 17.54-21.31), and negative LR 0.13 (95% CI 0.11-0.16). CONCLUSION: Software algorithms can assist in screening healthcare visit records. When combined with clinician review, they enable accurate identification of OM visits from non-coded records.
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Algoritmos , Programas de Rastreamento , Otite Média , Atenção Primária à Saúde , Encaminhamento e Consulta , Software , Humanos , Otite Média/diagnóstico , Atenção Primária à Saúde/estatística & dados numéricos , Lactente , Pré-Escolar , Masculino , Feminino , Recém-Nascido , Sensibilidade e Especificidade , Encaminhamento e Consulta/estatística & dados numéricos , Programas de Rastreamento/métodos , Registros Eletrônicos de SaúdeRESUMO
INTRODUCTION: Cancer care in humanitarian settings is very challenging, and patients may face significant barriers to accessing the care they need. This study explored access to advanced diagnostic and treatment services for children with cancer in humanitarian settings, taking Gaza as a case study. METHODS: The study was based on 51 key informant interviews and two focus group discussions with close relatives of children with cancer, healthcare providers and Ministry of Health officials between November 2021 and January 2022. We also analysed referral data for paediatric oncology care outside Gaza in 2021. RESULTS: Among the structural barriers to cancer care are complex and lengthy referral mechanisms, along with an unclear permit system. These challenges contribute to significant delays in both diagnosis and the initiation of treatment. The referral pathway involves multiple administrative and logistical steps to secure approval for treatment outside Gaza. It begins with a physician-initiated referral, approval of the Ministry of Health Service Purchasing Unit, and concludes with exit permit requests for the child and a companion, which must be approved by the Israeli Gaza Coordination and Liaison Administration. Analysis of 2021 referral data reveals that 25% of children with cancer experienced permit delays of over 1 month, and 8% died while waiting for an exit permit. CONCLUSIONS: The urgent need to scale up cancer care in Gaza is critical, particularly for children who face severe challenges due to ongoing conflict, the Israeli blockade since 2006 and the closure of the only paediatric oncology department. Immediate, coordinated national and global efforts are essential to overcome political, medical and financial barriers. Improving health outcomes and survival for children with cancer in Gaza requires addressing the root causes of late diagnosis, as well as the complex referral and unclear permit processes that delay timely access to specialised care.
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Acessibilidade aos Serviços de Saúde , Neoplasias , Humanos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Neoplasias/terapia , Neoplasias/diagnóstico , Criança , Oriente Médio/epidemiologia , Estudos Transversais , Masculino , Encaminhamento e Consulta/estatística & dados numéricos , Feminino , Grupos Focais , Pré-Escolar , AdolescenteRESUMO
PURPOSE: Multidisciplinary team (MDT) consultations are crucial for managing pulmonary nodules, yet face challenges in efficiency, evidence-based decision support, and data utilization within the MDT process. We present an integrated artificial intelligence (AI)-MDT platform that serves as an assistive tool for lung cancer MDT workflows by incorporating AI across various processes.The aim of this study is to evaluate the clinical utility and preliminary efficacy of the AI-MDT platform. METHODS: The platform comprises three core modules: process automation, intelligent decision support, and diagnostic assistance. It integrates a real-time, evidence-based knowledge base powered by large language models and deep learning, with computer vision for automatic lesion detection and feature analysis. A web-based interface allows users to interact seamlessly with the AI-MDT platform. RESULTS: Since its implementation in November 2023 at a tertiary Grade A hospital in China, the platform has been involved in 879 consultations, including 811 patients. AI-generated diagnostic recommendations were utilized 852 times, and decision-making support was used in 744 cases. The platform significantly increased consultation volume, reduced expert time, and enhanced data utilization compared to traditional MDT. CONCLUSIONS: It offers clinicians tools to improve diagnostic quality and work efficiency, highlighting its significant clinical application value. These findings suggest that the proposed platform contributes to the emerging research on advances precision lung cancer management by integrating a continually updated evidence base and intelligent imaging methodologies, having potential implications for MDT processes across various medical specialties.
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Inteligência Artificial , Neoplasias Pulmonares , Equipe de Assistência ao Paciente , Encaminhamento e Consulta , Humanos , Neoplasias Pulmonares/diagnóstico , Feminino , Masculino , Aprendizagem ProfundaRESUMO
BACKGROUND: The incidence of major lower extremity amputation (MLA) is related to increasing rates of diabetes mellitus and peripheral arterial disease. Factors which influence functional mobility following MLA are less known. We aimed to investigate determinants of improved prosthetic fitting rate and greater functional mobility following MLA in patients with vascular disease. METHODS: We performed a retrospective analysis of adults who underwent MLA for vascular disease at a tertiary center from June 2016 to November 2022. Patients were stratified by prosthesis fitting completion. Functional mobility was recorded using Prosthetic Limb Users Survey of Mobility (PLUS-M) scoring. Multivariate logistic regression was performed to identify factors associated with improved functional mobility. RESULTS: Three hundred sixty-one amputations in 350 patients were included in the study. Prosthesis fitting was completed following 134 (37.1%) amputations. Ninety-two patients had documented ambulation after fitting, and 82 (61.2%) patients recorded a PLUS-M score. Thirty-four PLUS-M scores (41.5%) achieved mobility above mean normative PLUS-M score, and 48 (58.5%) did not. Patients with above-average mobility had fewer comorbidities, had a higher incidence of prior coronary artery bypass graft (CABG), were more likely to have private insurance or Medicare, and were more likely to be discharged home or to acute rehab instead of a skilled nursing facility. On multivariate logistic regression, hypertension, cerebrovascular disease, and Medicaid insurance were associated with below-average mobility. CONCLUSION: In patients with vascular disease who undergo MLA, prior CABG and private or Medicare insurance were associated with above-average mobility. Efforts to achieve home discharge or acute rehab following MLA may improve functional outcomes.
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Amputação Cirúrgica , Membros Artificiais , Extremidade Inferior , Doença Arterial Periférica , Encaminhamento e Consulta , Humanos , Masculino , Estudos Retrospectivos , Feminino , Amputação Cirúrgica/efeitos adversos , Idoso , Pessoa de Meia-Idade , Extremidade Inferior/irrigação sanguínea , Resultado do Tratamento , Fatores de Risco , Fatores de Tempo , Recuperação de Função Fisiológica , Ajuste de Prótese , Doença Arterial Periférica/cirurgia , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/diagnóstico , Limitação da Mobilidade , Idoso de 80 Anos ou mais , Estado FuncionalRESUMO
Hospital readmissions within 30 days are a significant concern due to their negative impact on patient outcomes and healthcare system costs.1 This retrospective study explores the impact of palliative medicine consultation on reducing readmission rates for patients with severe, life-limiting illnesses. Real-world data from a 21-hospital system was analyzed for six specific diagnoses, including heart failure, sepsis, pneumonia, and chronic obstructive pulmonary disease. The study found a statistically significant reduction in readmissions for patients with sepsis, pneumonia, heart failure and (to a lesser extent) stroke who received palliative medicine consultation compared to those who did not. The findings suggest that palliative medicine consultation for these patients leads to reduced readmission and implies potential improved quality outcomes and cost savings. This study highlights the potential of palliative medicine as a multifactorial approach to reduce readmissions and potentially improve patient outcomes in the future.
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Cuidados Paliativos , Medicina Paliativa , Readmissão do Paciente , Encaminhamento e Consulta , Humanos , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Masculino , Feminino , Idoso , Cuidados Paliativos/organização & administração , Cuidados Paliativos/estatística & dados numéricos , Encaminhamento e Consulta/organização & administração , Encaminhamento e Consulta/estatística & dados numéricos , Pessoa de Meia-Idade , Insuficiência Cardíaca/terapia , Idoso de 80 Anos ou mais , Doença Pulmonar Obstrutiva Crônica/terapia , Sepse/terapia , Medicina Paliativa/organização & administração , Pneumonia/terapiaRESUMO
BACKGROUND: Child neurologists provide care for children with complex chronic health conditions often accompanied by logistical and emotional complexities, as well as acute decision-making scenarios. Pediatric neuropalliative medicine is a nascent subspecialty that aims to augment standard child neurology practice by attending to not only the physical domains of neurologic disease but also the nonphysical issues that accompany advancing illness. The perceptions of clinicians who refer families for this kind of care have not previously been elucidated. METHODS: This survey project queried referrers to a newly established pediatric neuropalliative medicine clinic to characterize their perceptions, including barriers and facilitators of referral and the impact of this service line on clinicians. Specifically, the authors sought to understand whether neurologists viewed this clinic differently than other referring clinicians. RESULTS: A total of 94 surveys were completed, with 22% (n = 21) of respondents being neurology clinicians and 78% (n = 73) representing other pediatric specialties. Neurology clinicians were significantly more likely to report a preference for a neurologist in the palliative medicine role (76% of neurologists vs 16% of non-neurologists, P < 0.001). While all referrers identified at least one benefit of referral to this clinic, neurologists were more likely to report that this new resource positively impacted their understanding of palliative medicine and their ability to devote more energy to their area of focus. CONCLUSIONS: Pediatric neuropalliative expertise is valued by referring clinicians, with the greatest impact described by neurologists. Referrers noted benefit to patient care as well as enhancement in professional domains.
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Atitude do Pessoal de Saúde , Neurologistas , Neurologia , Pediatria , Encaminhamento e Consulta , Humanos , Encaminhamento e Consulta/estatística & dados numéricos , Feminino , Masculino , Criança , Cuidados PaliativosRESUMO
BACKGROUND: Pulmonary tuberculosis remains a leading infectious disease globally. In Indonesia, coexisting noncommunicable diseases are increasing referral care use and total spending in the National Health Insurance program. Using 2022 national insurance claims data, this study aimed to estimate the financial impact of noncommunicable comorbidities among individuals with pulmonary tuberculosis. METHODS: This study follows cross-sectional study design, utilizing the Indonesian National Health Insurance contextual tuberculosis sample data. The study included individuals newly diagnosed with pulmonary tuberculosis in 2022. Individuals were classified into three categories based on the presence of noncommunicable comorbidities: none, single, and multiple. A marginalized two-part model was applied. First, logistic regression was fitted to estimate the likelihood of any referral care utilization. Second, a generalized linear model with a log link and log-normal distribution to analyze positive healthcare expenditures. RESULT: Noncommunicable comorbidity was strongly associated with higher referral care utilization and greater healthcare expenditures. Compared with individuals without noncommunicable comorbidities, those with one noncommunicable disease had an adjusted odds ratio of 201.22 (95â¯% CI, 148.77-272.16) and a cost ratio of 1.63 (95â¯% CI, 1.59-1.68). Individuals with multiple noncommunicable diseases had an adjusted odds ratio of 206.69 (95â¯% CI, 121.32-352.13) and a cost ratio of 3.23 (95â¯% CI, 3.10-3.37). The average annual expenditure increased from 188.48 USD among individuals without noncommunicable diseases to 416.85 USD for those with single, and 762.80 USD for those with multiple noncommunicable diseases. A significant (78.23â¯%) pulmonary tuberculosis individuals without noncommunicable disease comorbidity utilized referral care. CONCLUSIONS: This study reports that individuals with pulmonary tuberculosis who also have noncommunicable diseases face a much heavier financial burden within Indonesia's National Health Insurance program. Strengthening primary care and integrating tuberculosis and noncommunicable disease management should be implemented to reduce costs and improve health outcomes.
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Efeitos Psicossociais da Doença , Gastos em Saúde , Programas Nacionais de Saúde , Aceitação pelo Paciente de Cuidados de Saúde , Encaminhamento e Consulta , Tuberculose Pulmonar , Humanos , Tuberculose Pulmonar/economia , Tuberculose Pulmonar/epidemiologia , Indonésia/epidemiologia , Feminino , Masculino , Adulto , Estudos Transversais , Pessoa de Meia-Idade , Comorbidade , Programas Nacionais de Saúde/economia , Programas Nacionais de Saúde/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Encaminhamento e Consulta/economia , Adulto Jovem , Gastos em Saúde/estatística & dados numéricos , Adolescente , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , IdosoRESUMO
OBJECTIVE: To systematically describe characteristics of diagnostic error in referrals to the ophthalmology subspecialty of corneal and external disease. DESIGN: Retrospective diagnostic accuracy and validity analysis. PARTICIPANTS: All consecutive new patient referrals to a tertiary care academic cornea clinic from November 2021 to May 2022. METHODS: We analyzed medical records of 118 patients to extract diagnoses determined by referring and referral providers. Among the subset identified as diagnostic error cases, we further analyzed patterns, common pitfalls, cause of error using the Diagnosis Error Evaluation and Research (DEER) Taxonomy, presence of naming ambiguity, frequency of disease occurrences, and time to final diagnosis and treatment. MAIN OUTCOME MEASURES: Primary outcome measure was percentage of total cases with diagnostic error. Secondary outcome measures included frequencies of specific ophthalmologic conditions among several categories of diagnostic error (missed, wrong, or ambiguous), error type per the DEER Taxonomy, and time to diagnosis and treatment. RESULTS: Diagnostic error rate was 42%. Most (80%) cases were referred by ophthalmologists. Ambiguity in diagnostic terminology (DA) contributed to 25 of the 49 (51%) diagnostic error cases. DA cases suffered from delays in diagnosis and treatment similar to cases of frank diagnostic error (traditional DE). Misdiagnosis extended beyond a year in 5 of 25 DA cases and 1 of 24 traditional DE cases; symptomatic burden extended beyond a year in 10 of 25 DA cases and 9 of 24 traditional DE cases. Common diagnostic errors leading to ineffective treatment included: missing the diagnosis of ocular neuropathic pain despite absence of ocular surface disease and failing to identify exposure keratopathy, especially as a consequence of nocturnal lagophthalmos. All diagnostic error cases were caused by failures in history-taking or physical examination. CONCLUSIONS: Among referrals to an academic cornea and external disease practice, diagnostic error was predominantly localized to the history or physical examination. We identified ambiguous diagnostic language as an important type of diagnostic error and found that this leads to delay in successful therapy to the same extent as outright misdiagnosis. Addressing cognitive biases during ophthalmological training may be an actionable strategy to prevent error and harmful effects on patients.
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Doenças da Córnea , Erros de Diagnóstico , Oftalmologia , Encaminhamento e Consulta , Humanos , Erros de Diagnóstico/estatística & dados numéricos , Estudos Retrospectivos , Encaminhamento e Consulta/estatística & dados numéricos , Doenças da Córnea/diagnóstico , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Centros Médicos Acadêmicos , Adulto , Idoso de 80 Anos ou maisRESUMO
BackgroundPrevious research suggests that physicians' inclination to refer patients for suspected cancer is a relatively stable characteristic of their decision making. We aimed to identify its psychological determinants in the presence of a risk-prediction algorithm.MethodsWe presented 200 UK general practitioners with online vignettes describing patients with possible colorectal cancer. Per the vignette, GPs indicated the likelihood of referral (from highly unlikely to highly likely) and level of cancer risk (negligible/low/medium/high), received an algorithmic risk estimate, and could then revise their responses. After completing the vignettes, GPs responded to questions about their values with regard to harms and benefits of cancer referral for different stakeholders, perceived severity of errors, acceptance of false alarms, and attitudes to uncertainty. We tested whether these values and attitudes predicted their earlier referral decisions.ResultsThe algorithm significantly reduced both referral likelihood (b = -0.06 [-0.10, -0.007], P = 0.025) and risk level (b = -0.14 [-0.17, -0.11], P < 0.001). The strongest predictor of referral was the value GPs attached to patient benefits (b = 0.30 [0.23, 0.36], P < 0.001), followed by benefits (b = 0.18 [0.11, 0.24], P < 0.001) and harms (b = -0.14 [-0.21, -0.08], P < 0.001) to the health system/society. The perceived severity of missing a cancer vis-à-vis overreferring also predicted referral (b = 0.004 [0.001, 0.007], P = 0.009). The algorithm did not significantly reduce the impact of these variables on referral decisions.ConclusionsThe decision to refer patients who might have cancer can be influenced by how physicians perceive and value the potential benefits and harms of referral primarily for patients and the moral seriousness of missing a cancer vis-à-vis over-referring. These values contribute to an internal threshold for action and are important even when an algorithm informs risk judgments.HighlightsPhysicians' inclination to refer patients for suspected cancer is determined by their assessment of cancer risk but also their core values; specifically, their values in relation to the perceived benefits and harms of referrals and the seriousness of missing a cancer compared with overreferring.We observed a moral prioritization of referral decision making, in which considerations about benefits to the patient were foremost, considerations about benefits but also harms to the health system or the society were second, while considerations about oneself carried little or no weight.Having an algorithm informing assessments of risk influences referral decisions but does not remove or significantly reduce the influence of physicians' core values.
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Algoritmos , Neoplasias Colorretais , Clínicos Gerais , Encaminhamento e Consulta , Humanos , Encaminhamento e Consulta/estatística & dados numéricos , Encaminhamento e Consulta/normas , Feminino , Masculino , Medição de Risco/métodos , Pessoa de Meia-Idade , Reino Unido , Neoplasias Colorretais/diagnóstico , Lógica Fuzzy , Adulto , Tomada de Decisões , Inquéritos e Questionários , Clínicos Gerais/psicologia , Atitude do Pessoal de Saúde , Algoritmos de PrediçãoRESUMO
INTRODUCTION: Adherence to clinical guidelines in the management of testicular germ-cell cancer ensures optimal oncological outcomes, minimizes the risk of overtreatment and undertreatment, and reduces unnecessary investigations including radiographic imaging. An interdisciplinary testis cancer clinic (ITCC) in the Department of urology of the University Hospital Zürich was therefore established in 2016 led by a urologist and medical oncologist, who had both specialized in germ-cell cancer. Aside from treatment decision visits, structured follow-up schedules were integrated to guarantee guideline-conformant therapy and follow-up. We aimed to evaluate the impact of the ITCC on guideline adherence and follow-up. MATERIALS AND METHODS: A retrospective analysis was conducted on all testicular germ-cell cancer patients treated from 2012 to 2020 in our hospital. Patients were categorized into 2 groups: those followed prior to the establishment of the ITCC and those thereafter. We compared patient characteristics, follow-up protocols, and the compliance with guideline-recommended follow-up schedules. RESULTS: We included 143 patients, with 77 in the pre-ITCC group and 66 in the ITCC group. Adherence to clinical follow-up guidelines over a 5-year period was significantly higher in the ITCC group, with 89% completeness of the recommended consultations and diagnostics compared to only 21% in the pre-ITCC group. Additionally, the median number of computed tomography scans was significantly lower in the ITCC group during each of the 5 years of follow-up. The time between orchiectomy and start of further therapies was significantly shorter in the ITCC group (median 24 days versus 32 days, P < 0.01) and significantly less patients were lost to follow-up (11% versus 36%, P < 0.001). CONCLUSIONS: A well-structured ITCC can improve the quality of care of testis cancer patients by optimizing adherence to follow-up schedules and therefore expediting further therapies, reducing unnecessary diagnostics and minimizing loss to follow-up.
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Neoplasias Embrionárias de Células Germinativas , Equipe de Assistência ao Paciente , Melhoria de Qualidade , Neoplasias Testiculares , Melhoria de Qualidade/organização & administração , Melhoria de Qualidade/normas , Fidelidade a Diretrizes/organização & administração , Fidelidade a Diretrizes/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Neoplasias Embrionárias de Células Germinativas/diagnóstico , Neoplasias Embrionárias de Células Germinativas/mortalidade , Neoplasias Embrionárias de Células Germinativas/terapia , Neoplasias Testiculares/diagnóstico , Neoplasias Testiculares/mortalidade , Neoplasias Testiculares/terapia , Implementação de Plano de Saúde/organização & administração , Implementação de Plano de Saúde/normas , Equipe de Assistência ao Paciente/organização & administração , Equipe de Assistência ao Paciente/normas , Equipe de Assistência ao Paciente/estatística & dados numéricos , Estudos Retrospectivos , Urologistas/organização & administração , Urologistas/normas , Oncologistas/organização & administração , Oncologistas/normas , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos , Assistência ao Convalescente/organização & administração , Assistência ao Convalescente/normas , Assistência ao Convalescente/estatística & dados numéricos , Humanos , Masculino , AdultoRESUMO
It is inevitable that every orthopaedic surgeon will need to treat patients with pathologic or impending pathologic fractures secondary to metastatic disease. Although the input of an orthopaedic oncologist is usually helpful and prudent, transferring care to an orthopaedic oncologist may not be feasible at all institutions in a prompt time frame. To avoid potentially detrimental delays to the patient, many cases can be appropriately managed or resolved by a nononcologic orthopaedic surgeon. It is therefore imperative for all orthopaedic surgeons to be familiar with the appropriate clinical and surgical principles of treating patients presenting with pathologic fractures. This starts with establishing that the pathologic fracture is indeed secondary to metastatic disease rather than a primary bone sarcoma, deciding which patients need surgery rather than nonsurgical modalities such as medicine and radiation, and understanding the unique surgical challenges that pathologic fractures present such as excess intraoperative bleeding, poor potential for bone healing, high chance of concomitant other destructive bone lesions in the same bone, and a high risk of postsurgical complications such as thromboembolic events. Although certain patient presentations and fracture patterns are certainly suitable for a nononcologic orthopaedic surgeon to aptly treat, certain complex clinical presentations or fracture patterns requiring complex surgical reconstructions may best be suited for referral to an orthopaedic oncologist or even a collaborative approach between an orthopaedic oncologist and another orthopaedic subspecialist. It is important to highlight some of these facets of pathologic fracture management, review general principles for the orthopaedic surgeon from both an orthopaedic oncologist perspective and a nononcologist perspective, discuss anatomic areas that have subtleties and controversies in their treatment such as the pelvis and acetabulum, and examine advances in management of pathologic fractures of the upper extremity and shoulder, which have benefitted from the interdisciplinary collaboration of orthopaedic oncologists and shoulder arthroplasty surgeons.
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Neoplasias Ósseas , Fraturas Espontâneas , Humanos , Neoplasias Ósseas/secundário , Neoplasias Ósseas/complicações , Neoplasias Ósseas/cirurgia , Fraturas Espontâneas/etiologia , Fraturas Espontâneas/cirurgia , Fraturas Espontâneas/terapia , Ortopedia , Encaminhamento e ConsultaRESUMO
OBJECTIVE: The objective of this study was to conduct a national survey of practicing dentists to assess their current knowledge, attitudes, and practice behaviors related to substance use screening among their adult patients. The secondary objective was to identify practitioner- and practice-level facilitators and barriers to substance use screening. METHOD: This cross-sectional study consisted of an electronic survey disseminated to practicing dentists who were active members of the National Dental Practice-Based Research Network (n = 790; 61% male). RESULTS: The majority of dentists reported some level of screening for nicotine (95.7%), alcohol (87.2%), cannabis (83.9%), and illicit drug (87.7%) use among their adult patients. More than 2 in 5 dentists reported never counseling patients regarding problematic use of alcohol, cannabis, and illicit drugs. Higher screening frequency was associated with higher counseling frequency and lower endorsement of two barrier factors: beliefs regarding responsibility, relevance, and effectiveness, and lack of training and/or resources. Higher frequency of counseling was associated with higher frequency of referral behavior and lower endorsement of three barrier factors: concerns regarding patient truthfulness/discomfort; beliefs regarding responsibility, relevance, and effectiveness; and lack of training and/or resources. CONCLUSIONS: Results indicate a high level of willingness to screen, counsel, and refer patients for substance use among a majority of dentists, although current practice behaviors lag willingness. Findings regarding barriers and facilitators can guide efforts to develop, disseminate, and implement screening, brief intervention, and referral to treatment training, initiatives, and tools that are inclusive of or specifically target dental providers.
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Aconselhamento , Odontólogos , Programas de Rastreamento , Padrões de Prática Odontológica , Encaminhamento e Consulta , Transtornos Relacionados ao Uso de Substâncias , Humanos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/terapia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Masculino , Encaminhamento e Consulta/estatística & dados numéricos , Estudos Transversais , Feminino , Aconselhamento/estatística & dados numéricos , Aconselhamento/métodos , Adulto , Pessoa de Meia-Idade , Padrões de Prática Odontológica/estatística & dados numéricos , Programas de Rastreamento/métodos , Estados Unidos , Atitude do Pessoal de Saúde , Conhecimentos, Atitudes e Prática em SaúdeRESUMO
PurposeDescribe the Perspectives of Psychiatry approach and how it was integrated into an employer-based mental health engagement program.DesignRetrospective cohort study.SettingWorkplace-based.Sample913 employees.InterventionThe Johns Hopkins Balance program is a novel, employer-initiated mental health engagement program. The Balance program integrates the Perspectives of Psychiatry (Perspectives) ideology for mental health care and takes a population health and psychoeducational approach to screening and care connection.MeasuresUtilization and engagement rates, algorithm-based mental health symptom risk, Perspectives-based risk.AnalysisChi squared tests for risk categorization associations, odds ratio high risk categorization, frequency and percentage of referral types.Results94% (860/913) of participants who registered completed the Balance assessment and 14% (130/913) completed a care concierge visit. Referrals were placed for 69% (90/130) of employees who completed a care concierge visit. A person identified as high risk by the standardized assessments had 6.74 (4.38, 10.71) times the odds of endorsing a concern on at least one of the Perspectives. An additional 28 participants were identified as high risk based on their own concern after scoring low risk on the standardized assessment. Of the 117 referrals placed, 96.6% (113/117) were in individuals scoring high risk on the assessment.ConclusionA population health and psychoeducational approach to employer-based mental health engagement can successfully identify risk and connect employees to care.