Patient-reported outcome, clinician-reported outcome, and patient satisfaction with treatment by crisis resolution teams: a multicenter pre-post study of outcome and associated factors in Norway.

BACKGROUND: Crisis resolution teams (CRTs) have become a part of mental health services in many high-income countries. Many studies have investigated the impact of CRTs on acute admissions to inpatient units, but very few studies have investigated patient-reported and clinician-reported outcomes for CRT service users. Our aims were to study patient-reported and clinician-reported outcomes of CRT treatment, how the outcomes were associated with characteristics of the service user and the treatment, and whether outcomes were different across CRTs. METHODS: The study was a pre-post observational multicenter study of 475 patients receiving treatment from 25 CRTs in urban and rural areas in Norway. There was no control group. Outcomes were change in mental health status reported by service users using CORE-10 and by clinicians using HoNOS. Patient satisfaction was measured using CSQ-8 at the end of the treatment. Components of CRT accessibility and interventions were measured by clinicians reporting details on each session with the service user. CRT model fidelity was measured using the CORE CRT Fidelity Scale version 2. We used paired t-tests to analyze outcomes and linear mixed modeling to analyze associations of the outcomes with the characteristics of service users and the treatment provided. Using independent t-tests, we analyzed differences in outcomes and patient satisfaction between two clusters of CRTs with differences in accessibility. RESULTS: The patient-reported outcomes and the clinician-reported outcomes were significantly positive and with a large effect size. Both were significantly positively associated with practical support and medication management and negatively associated with collaboration with mental health inpatient units. Patient satisfaction was high at the end of the treatment. CRTs with higher accessibility had a significantly better clinician-reported outcome, but no significant differences were reported for patient-reported outcomes or patient satisfaction. CONCLUSIONS: CRT treatment led to improved symptom status as reported by patients and clinicians, as well as high patient satisfaction. Practical support and medication management were the interventions most strongly associated with positive outcomes. Some of the variations in outcomes were at the team level. Patient- and clinician-reported outcomes should be used more in studies on the effect of treatment provided by crisis resolution teams.

Experiences of recovery and posthospital care needs of working-age adults after physical trauma: a qualitative focus group study.

OBJECTIVE: To explore experiences of recovery after physical trauma and identify long-term needs for posthospital care. DESIGN, PARTICIPANTS AND SETTING: A qualitative study was conducted consisting of seven online focus groups among working-age adults who sustained their injury between 9 months and 5 years ago. Trauma patients discharged from a level 1 trauma centre in the Netherlands were divided into three groups based on the type of their physical trauma (monotrauma, polytrauma and traumatic brain injury). Group interviews were transcribed verbatim, and thematic analysis was conducted. RESULTS: Despite differences in type and severity of their injuries, participants all struggled with the impact that trauma had on various aspects of their lives. They experienced recovery as an unpredictable and inconstant process aimed at resuming a meaningful life. Work was often perceived as an important part of recovery, though the value attributed to work could change over time. Participants struggled to bring the difficulties they encountered in their daily lives and at work to the attention of healthcare professionals (HCPs). While posthospital care needs varied between and across groups, all people stressed the need for flexible access to person-centred, multidisciplinary care and support after hospital discharge. CONCLUSIONS: This study reveals that people with a broad variety of injury experience recovery as a process towards resuming a meaningful life and report the need to expand trauma care to include comprehensive support to live well long term. Person-centred care might be helpful to enable HCPs to take people's individual long-term needs and life situations into account. Furthermore, providing timely access to coordinated, multidisciplinary care after discharge is advocated. Integrated care models that span a network of multidisciplinary support around the person may help align existing services and may facilitate easy and timely access to the most suitable support for injured people and their loved ones.

Patients at the centre after a health care incident: A scoping review of hospital strategies targeting communication and nonmaterial restoration.

OBJECTIVE: This study aimed to provide an overview of the strategies adopted by hospitals that target effective communication and nonmaterial restoration (i.e., without a financial or material focus) after health care incidents, and to formulate elements in hospital strategies that patients consider essential by analysing how patients have evaluated these strategies. BACKGROUND: In the aftermath of a health care incident, hospitals are tasked with responding to the patients' material and nonmaterial needs, mainly restoration and communication. Currently, an overview of these strategies is lacking. In particular, a gap exists concerning how patients evaluate these strategies. SEARCH STRATEGY AND INCLUSION CRITERIA: To identify studies in this scoping review, and following the methodological framework set out by Arksey and O'Malley, seven subject-relevant electronic databases were used (PubMed, Medline, Embase, CINAHL, PsycARTICLES, PsycINFO and Psychology & Behavioral Sciences Collection). Reference lists of included studies were also checked for relevant studies. Studies were included if published in English, after 2000 and as peer-reviewed articles. MAIN RESULTS AND SYNTHESIS: The search yielded 13,989 hits. The review has a final inclusion of 16 studies. The inclusion led to an analysis of five different hospital strategies: open disclosure processes, communication-and-resolution programmes, complaints procedures, patients-as-partners in learning from health care incidents and subsequent disclosure, and mediation. The analysis showed three main domains that patients considered essential: interpersonal communication, organisation around disclosure and support, and desired outcomes. PATIENT CONTRIBUTION: This scoping review specifically takes the patient perspective in its methodological design and analysis. Studies were included if they contained an evaluation by patients, and the included studies were analysed on the essential elements for patients.

Shared Decision Making in Practice and the Perspectives of Health Care Professionals on Video-Recorded Consultations With Patients With Low Health Literacy in the Palliative Phase of Their Disease.

Introduction. An important goal of palliative care is improving the quality of life of patients and their partners/families. To attain this goal, requirements and preferences of patients need to be discussed, preferably through shared decision making (SDM). This enhances patient autonomy and patient-centeredness, requiring active participation by patients. This is demanding for palliative patients, and even more so for patients with limited health literacy (LHL). This study aimed to examine SDM in practice and assess health care professionals' perspectives on their own SDM. Methods. An explanatory sequential mixed methods design was used. Video recordings were gathered cross-sectionally of palliative care consultations with LHL patients (n = 36) conducted by specialized palliative care clinicians and professionals integrating a palliative approach. The consultations were observed for SDM using the OPTION5 instrument. Potential determinants of SDM were examined using multilevel analysis. Sequentially, stimulated recall interviews were conducted assessing the perspectives of professionals on their SDM (n = 19). Interviews were examined using deductive thematic content analysis. Results. The average SDM score in practice was moderate, varying greatly between professionals, as shown by the multilevel analysis and by varying degrees of perceived patient involvement in SDM mentioned in the interviews. To improve this, professionals recommended 1) continuously discussing all options with patients, 2) allowing time for patients to talk, and 3) using strategic timing for involving patients in SDM. Discussion. The implementation of SDM for people with LHL in palliative care varies in quality and needs improvement. SDM needs to be enhanced in this care domain because decisions are complex and demanding for LHL patients. Future research is needed that focuses on supporting strategies for comprehensible SDM, best practices, and organizational adaptations.

Fidelity to an evidence-based model for crisis resolution teams: a cross-sectional multicentre study in Norway.

BACKGROUND: Crisis resolution teams (CRTs) are specialized multidisciplinary teams intended to provide assessment and short-term outpatient or home treatment as an alternative to hospital admission for people experiencing a mental health crisis. In Norway, CRTs have been established within mental health services throughout the country, but their fidelity to an evidence-based model for CRTs has been unknown. METHODS: We assessed fidelity to the evidence-based CRT model for 28 CRTs, using the CORE Crisis Resolution Team Fidelity Scale Version 2, a tool developed and first applied in the UK to measure adherence to a model of optimal CRT practice. The assessments were completed by evaluation teams based on written information, interviews, and review of patient records during a one-day visit with each CRT. RESULTS: The fidelity scale was applicable for assessing fidelity of Norwegian CRTs to the CRT model. On a scale 1 to 5, the mean fidelity score was low (2.75) and with a moderate variation of fidelity across the teams. The CRTs had highest scores on the content and delivery of care subscale, and lowest on the location and timing of care subscale. Scores were high on items measuring comprehensive assessment, psychological interventions, visit length, service users' choice of location, and of type of support. However, scores were low on opening hours, gatekeeping acute psychiatric beds, facilitating early hospital discharge, intensity of contact, providing medication, and providing practical support. CONCLUSIONS: The CORE CRT Fidelity Scale was applicable and relevant to assessment of Norwegian CRTs and may be used to guide further development in clinical practice and research. Lower fidelity and differences in fidelity patterns compared to the UK teams may indicate that Norwegian teams are more focused on early interventions to a broader patient group and less on avoiding acute inpatient admissions for patients with severe mental illness.

Examining the Intended and Unintended Impacts of Raising a Minimum Legal Drinking Age on Primary and Secondary Societal Harm and Violence from a Contextual Policy Perspective: A Scoping Review.

Raising a minimum legal drinking age (MLDA) has generated interest and debate in research and politics, but opposition persists. Up to now, the presentation of impacts focussed on effectiveness (i.e., intended impact); to our knowledge, no literature syntheses focussed on both intended and unintended impacts. A systematic scoping review was conducted in which a search strategy was developed iteratively and literature was obtained from experts in alcohol research and scientific and grey databases. Ninety-one studies were extracted and analysed using formative thematic content analysis. Intended impacts were reported in 119 units of information from the studies (68% positive), forming four paths: implementation, primary and (two) on secondary societal harm and violence. Unintended developments were reported in 43 units of information (30% positive), forming five themes. Only eight studies reported on implementation. Furthermore, a division between primary and secondary paths and the use of a bridging variable (drinking patterns in analyses or methodology) was discovered. These results provide an insight into how well legislation works and can be used to discover or implement new means of curbing underage drinking and alcohol-related violence and harm. They also offer valuable starting points for future research and underline the importance of considering unintended developments.

The effect of medication related clinical decision support at the time of physician order entry.

Background In advanced clinical decision support systems, patient characteristics and laboratory values are included in the algorithms that generate alerts. These alerts have a higher specificity than basic medication surveillance alerts. The alerts of advanced clinical decision support systems can be shown directly to the prescriber during order entry, without the risk of generating an overload of irrelevant alerts. We implemented five advanced algorithms that are shown directly to the prescriber. These algorithms are for gastrointestinal prophylaxis, folic or folinic acid prescribed with orally or subcutaneously administered methotrexate, vitamin D prescribed with bisphosphonates, hyponatremia and measuring plasma levels for vancomycin and gentamicin. Objective We evaluated the effect of the implementation of the algorithms. Setting We performed prospective intervention studies with a historical group for comparison in both inpatients and outpatients at a teaching hospital in the Netherlands. Methods We compared the time period after implementation of the algorithm with the time period before implementation, using data from the hospital information system Epic. Difference in guideline adherence were analyzed using Chi square tests. Main outcome measure The outcome measures were the number of alerts, the acceptance rate of the advice in the alert, and for the algorithm measuring plasma levels for vancomycin and gentamicin the time to the correct dose. Results For all algorithms, the implementation resulted in a significant increase in guideline adherence, varying from 11 to 36%. The acceptance rate varied from 14% for hyponatremia to 90% for methotrexate. For gastrointestinal prophylaxis the acceptance rate was 4.4% for basic drug-drug interaction alerts when no gastrointestinal prophylaxis was prescribed and increased to 44.7% after implementation of the advanced algorithm. This algorithm substantially decreased the number of alerts from 812 before implementation to 217 after implementation. After implementation of the algorithm for measuring plasma levels for vancomycin and gentamicin, the proportion of patients receiving the correct dose after 48 h increased from 73 to 84% (p = 0.03). Conclusion Implementation of advanced algorithms that take patient characteristics into account and are shown directly to the physician during order entry, result in an increased guideline adherence.

The Right Time and Place: A New Approach for Prioritizing Alcohol Enforcement and Prevention Efforts by Combining the Prevalence and the Success Rate for Minors Purchasing Alcohol Themselves.

OBJECTIVE: In the Netherlands, enforcement of the alcohol age limit is low and inconsistent because of limited resources. A solution is to optimize the efforts of enforcement officers by prioritizing ways in which they regulate commercial alcohol availability. This could increase compliance by sellers, curbing commercial availability. The objective of this study is to present the development of a commercial alcohol availability estimate (CAAE) for all vendor types selling alcohol and to propose a priority ranking. METHOD: A multi-method design was used, combining data (collected in 2015) from national studies reporting behavior of minors purchasing alcohol themselves and the success rate (noncompliance) of alcohol vendors (interviewing 510 minors by telephone and conducting 1,373 purchase attempts of alcohol by minors, respectively). Descriptive data and the development of the CAAE are presented. RESULTS: Compared with other vendor types (e.g., sports bars or supermarkets), bars/cafes/discos scored highest on the CAAE, indicating that 7.7% of 16- to 17-year-olds in the survey reported successfully purchasing their own alcohol at this vendor type. CONCLUSIONS: To control commercial alcohol availability efficiently for minors in the Netherlands, our estimates suggest that enforcement and prevention efforts should prioritize bars/cafes/discos. However, local authorities should also consider local circumstances and maintain a base amount of attention for all vendor types. Ultimately, the CAAE has the potential to improve enforcer capacity and efficiency in policing commercial alcohol regulation, and prevention workers could align their interventions or campaigns to high-ranked vendor types.

Measuring Fidelity to Evidence-Based Practices: Psychometrics.

This special section presents the psychometric properties of fidelity scales used in a national mental health services project in Norway to improve the quality of care of people with psychoses. Across Norway, 39 clinical units in six health trusts participated. The project provided education, implementation support and fidelity assessments. The papers in the section address the psychometrics of fidelity measurement for the specific evidence-based practices: illness management and recovery, family psychoeducation, physical healthcare and antipsychotic medication management. Another paper analyzes the psychometrics of a scale measuring individualization and quality improvement that may be used in conjunction with fidelity scales for specific evidence-based practices. The first paper in the section presents the development and field of fidelity scales, and the two final papers with comments add some additional perspectives and discuss fidelity scales in a wider context. The psychometrics of the five scales were good to excellent. Fidelity assessment is a necessary and effective strategy for quality improvement.

The Family Psychoeducation Fidelity Scale: Psychometric Properties.

This study examined psychometric properties and feasibility of the Family Psychoeducation (FPE) Fidelity Scale. Fidelity assessors conducted reviews using the FPE fidelity scale four times over 18 months at five sites in Norway. After completing fidelity reviews, assessors rated feasibility of the fidelity review process. The FPE fidelity scale showed excellent interrater reliability (.99), interrater item agreement (88%), and internal consistency (mean = .84 across four time points). By the 18-month follow-up, all five sites increased fidelity and three reached adequate fidelity. Fidelity assessors rated feasibility as excellent. The FPE fidelity scale has good psychometric properties and is feasible for evaluating the implementation of FPE programs. Trial registration ClinicalTrials.gov Identifier: NCT03271242.

Measuring implementation: development of the implementation process assessment tool (IPAT).

BACKGROUND: Implementation science comprises a large set of theories suggesting interacting factors at different organisational levels. Development of literature syntheses and frameworks for implementation have contributed to comprehensive descriptions of implementation. However, corresponding instruments for measuring these comprehensive descriptions are currently lacking. The present study aimed to develop an instrument measuring care providers' perceptions of an implementation effort, and to explore the instrument's psychometric properties. METHODS: Based on existing implementation literature, a questionnaire was designed with items on individual and team factors and on stages of change in an implementation process. The instrument was tested in a Norwegian study on implementation of evidence based practices for psychosis. Item analysis, factor structure, and internal consistency at baseline were examined. RESULTS: The 27-item Implementation Process Assessment Tool (IPAT) revealed large variation between mean score of the items. The total scale scores were widely dispersed across respondents. Internal consistency for the total scale was high (Cronbach's alpha: .962), and all but one item contributed positively to the construct. The results indicated four underlying constructs: individual stages for behavioural change, individual activities and perceived support, collective readiness and support, and individual perceptions of the intervention. CONCLUSIONS: The IPAT appears to be a feasible instrument for investigating the implementation process from the perspective of those making the change. It can enable examination of the relative importance of factors thought to be essential for implementation outcomes. It may also provide ongoing feedback for leaders tailoring support for teams to improve implementation. However, further research is needed to detect the instrument's properties later in the implementation process and in different contexts. TRIAL REGISTRATION: ClinicalTrials.gov code NCT03271242 (retrospective registered September 5, 2017).

A clinical decision support system to improve adequate dosing of gentamicin and vancomycin.

OBJECTIVE: Gentamicin and vancomycin meet the criteria for measuring plasma concentrations during therapy. However, compliance with the accompanying guidelines remains low. The primary objective of this study was to determine whether the implementation of a clinical decision support system, which displays an alert if a plasma concentration should be measured and a daily reviewed patient list resulted in improved compliance. MATERIALS AND METHODS: This intervention study was performed at the Spaarne Gasthuis, Haarlem/Hoofddorp, the Netherlands. The authors included 261 treatments with either gentamicin or vancomycin intravenously for at least 48 h in the year before and after implementation of the clinical decision support system in May 2015. The authors analyzed whether plasma concentrations were measured sooner and more frequently after the implementation, and determined whether the time until the correct dosage, with adequate drug concentrations, was reduced after implementation. RESULTS: Before implementation, plasma concentrations were measured within 72 h in 47% of the treatments. After implementation, this percentage increased to 80% (p < 0.01). After implementation, the time was significantly shorter until the correct dosage was given. CONCLUSION: The implementation of a clinical decision support system and a patient list resulted in improved compliance with the guidelines and optimized the treatment with gentamicin and vancomycin.

Can vendors' age limit control measures increase compliance with the alcohol age limit? An evaluation of measures implemented by three Dutch liquor store chains.

BACKGROUND: Dutch liquor store (off license) chains have voluntarily developed and implemented age limit control measures to increase compliance with the Licensing and Catering Act (LCA), aimed at prohibiting vendors from selling alcohol to minors (<18 years old). This study investigates differences between three liquor store chains in their style of self-regulation and how that affects compliance with the LCA in four domains (capturing processes in age verification, instructing staff, monitoring performance/providing feedback and imposing consequences). METHODS: A mixed-method design was used. In depth-interviews (n = 3) were conducted with chains' head office managers, gaining insight into control measures. Survey (n = 372) research was conducted to measure liquor store owners' perceptions of implementation. Mystery shop (n = 387) research was conducted to measure compliance of store owners with the LCA. Survey and mystery shopping data was linked (n = 179) for the indicated perceived risk of inspection. RESULTS: The interviews indicated that control measures differ across chains in comprehensiveness and degree of implementation, survey results showed corresponding differences across the chains. Linked results showed that liquor store owners who perceive a very high risk of inspection, showed higher ID requesting rates (chain 2 and 3: 93% and 99%) and compliance rates (chain 2 and 3: 77% and 86%), respectively. This effect may be amplified by a set of measures (e.g., by implementing age verification systems, increasing training, monitoring performances and/or imposing consequences) and could result in higher ID request rates (chain 1: 54% versus chain 2 and 3: both 95%) and compliance rates (chain 1: 35% versus chain 2 and 3: both 80%). CONCLUSION: A comprehensive and systematic implementation of specific combinations of control measures in all four domains resulted in high compliance rates up to 80%. Nevertheless, the expectation is that this effect can only be attained when complemented by external government enforcement efforts.

Development of a risk model for predicting QTc interval prolongation in patients using QTc-prolonging drugs.

Background Numerous drugs prolong the QTc interval on the ECG and potentially increase the risk of cardiac arrhythmia. This risk is clinically relevant in patients with additional risk factors. Objective The objective was to develop and validate a risk model to predict QTc interval prolongation of eligible ECGs. Setting Spaarne Gasthuis (Haarlem/Hoofddorp, The Netherlands). Method A dataset was created from ECGs recorded in patients using one or more QTc prolonging drugs, in the period January 2013 and October 2016. In the development set, independent risk factors for QTc interval prolongation were determined using binary logistic regression. Risk scores were assigned based on the beta coefficient. In the risk-score validation set, the area under the ROC-curve, sensitivity and specificity were calculated. Main outcome measure QTc interval prolongation, defined as a QTc interval > 500 ms. Results In the development set 12,949 ECGs were included and in the risk-score validation set 6391 ECGs. The proportion of ECGs with a prolonged QTc interval in patients with no risk factors in the risk-score validation set was 2.7%, while in patients with a high risk score the proportion was 26.1%. The area under the ROC curve was 0.71 (95% CI 0.68-0.73). The sensitivity and specificity were 0.81 and 0.48, respectively. Conclusion A risk model was developed and validated for the prediction of QTc interval prolongation. This risk model can be implemented in a clinical decision support system, supporting the management of the risks involved with QTc interval prolonging drugs.

Could You Buy Me a Beer? Measuring Secondary Supply of Alcohol in Dutch On-Premise Outlets.

OBJECTIVE: Alcohol is largely available for Dutch minors through on-premise secondary supply, which occurs when an adult furnishes an alcoholic drink to a minor in an on-premise outlet. Vendors allowing this secondary supply on their premises are in violation of the Dutch Licensing and Catering Act (legal age limit is 18 years old for the sale and possession of alcohol). Using existing mystery shopping protocols as a standard, our study objective was the development and field testing of a novel procedure, measuring vendors' compliance with secondary supply. METHOD: Using a newly developed mystery shopping procedure, transfers of alcohol between young adult buyers and minors were staged in 109 Dutch on-premise outlets (cafes and bars) to measure vendors' compliance with secondary supply. RESULTS: In accordance with the Dutch Licensing and Catering Act, 29% of the vendors disallowed the secondary supply of alcohol to minors (32 of 109 attempts). During 40 attempts (of 109 attempts; 37%), the vendor asked for the identification document (ID) of the minor. Compliance after the ID was requested was 80% (32 of 40 attempts). During 8 attempts (20%), the minors were served even after the ID of the minor was requested. CONCLUSIONS: Mystery shopping is a suitable methodology for measuring compliance with secondary supply. Results show that alcohol is largely available for Dutch minors through secondary supply. Governments that intend to formulate and evaluate enforcement policies aimed at curbing high alcohol availability for minors are advised to use this novel procedure for monitoring compliance and to use these results for agenda setting and benchmarking.

Risk factors for QTc interval prolongation.

PURPOSE: Prolongation of the QTc interval may result in Torsade de Pointes, a ventricular arrhythmia. Numerous risk factors for QTc interval prolongation have been described, including the use of certain drugs. In clinical practice, there is much debate about the management of the risks involved. In this study, we quantified the effect of these risk factors on the length of the QTc interval. METHODS: We analyzed all ECGs that were taken during routine practice between January 2013 and October 2016 in the Spaarne Gasthuis, a general teaching hospital in the Netherlands. We collected laboratory values in the week before the ECG recording and the drugs prescribed. For the identification of risk factors, we used multilevel linear regression analysis to correct for multiple ECG recordings per patient. RESULTS: We included 133,359 ECGs in our study, taken in 40,037 patients. Patients using one QT-prolonging drug had a 11.08 ms (95% CI 10.63-11.52; p < 0.001) longer QTc interval. Patients using two QT-prolonging drugs had a 3.04 ms (95% CI 2.06-4.02; p < 0.001) increase in the QTc interval compared to patients using one QT-prolonging drug. Women had a longer QTc interval compared to men (16.30 ms 95% CI 14.59-18.01; p < 0.001). The QTc interval increased with increasing age, but the difference between men and women diminished. Other independent risk factors that significantly prolonged the QTc interval with at least 10 ms were hypokalemia, hypocalcemia, and the use of loop diuretics. CONCLUSION: We identified and quantified various risk factors for QTc interval prolongation.

Post-traumatic stress disorder moderates the relationship between trauma exposure and chronic pain.

Background: Trauma exposure and post-traumatic stress disorder (PTSD) are risk factors for chronic pain. Objective: This study investigated how exposure to intentional and non-intentional traumatic events and PTSD are related to pain severity and outcome of treatment in chronic pain patients. Methods: We assessed exposure to potentially traumatizing events, psychiatric diagnosis with structured clinical interview, and pain severity in 63 patients at a secondary multidisciplinary pain clinic at the beginning of treatment, and assessed level of pain at follow up. Exposure to potentially traumatizing events and PTSD were regressed on pain severity at the initial session and at follow up in a set of multiple regression analysis. Results: The participants reported exposure to an average of four potentially traumatizing events, and 32% had PTSD. Exposure to intentional traumatic events and PTSD were significantly associated with more severe pain, and PTSD significantly moderated the relationship between trauma exposure and pain (all p < .05). The treatment programme reduced pain moderately, an effect that was unrelated to trauma exposure and PTSD. Conclusions: Trauma exposure is related to chronic pain in the same pattern as to mental disorders, with intentional trauma being most strongly related to pain severity. PTSD moderated the relationship between trauma exposure and pain. While pain patients with PTSD initially report more pain, they responded equally to specialist pain treatment as persons without PTSD.

Planteamiento: La exposición al trauma y el trastorno de estrés postraumático (TEPT) son factores de riesgo para el dolor crónico. Este estudio investigó cómo el TEPT y la exposición a acontecimientos traumáticos intencionales y no intencionales se relacionan con la gravedad del dolor y el resultado del tratamiento en pacientes con dolor crónico. Métodos: Al inicio del tratamiento, evaluamos la exposición a acontecimientos potencialmente traumatizantes, el diagnóstico psiquiátrico con la entrevista clínica estructurada y la gravedad del dolor en 63 pacientes de una clínica para el dolor multidisciplinaria secundaria. En el seguimiento, se evaluó el nivel de dolor. La exposición a acontecimientos potencialmente traumatizantes y al TEPT había retrocedido en cuanto a la gravedad del dolor en la sesión inicial y en el seguimiento en un conjunto de análisis de regresión múltiple. Resultados: Los participantes informaron de la exposición a un promedio de cuatro eventos potencialmente traumatizantes, y el 32% tenían TEPT. La exposición a eventos traumáticos intencionales y el TEPT se asociaron significativamente con dolor más intenso y el TEPT moderó significativamente la relación entre la exposición al trauma y el dolor (todos los valores p <0,05). El programa de tratamiento redujo el dolor moderadamente, efecto que no estaba relacionado con la exposición al trauma y el TEPT. Conclusiones: La exposición al trauma está relacionada con el dolor crónico de modo similar que con los trastornos mentales, siendo el trauma intencional el que está más intensamente relacionado con la gravedad del dolor. El TEPT moderó la relación entre la exposición al trauma y el dolor. Mientras que los pacientes con dolor y con TEPT inicialmente refirieron más dolor, respondieron del mismo modo al tratamiento especializado del dolor como las personas sin TEPT.

Increased minimum legal age for the sale of alcohol in the Netherlands as of 2014: The effect on alcohol sellers' compliance after one and two years.

BACKGROUND: As of January 2014, the Dutch minimum legal age for the sale and purchase of all alcoholic beverages has increased from 16 to 18 years of age. The effectiveness of a minimum legal age policy in controlling the availability of alcohol for adolescents depends on the extent to which this minimum legal age is complied with in the field. The main aim of the current study is to investigate, for a country with a West-European drinking culture, whether raising the minimum legal age for the sale of alcohol has influenced compliance rates among Dutch alcohol vendors. METHODS: A total of 1770 alcohol purchase attempts by 15-year-old mystery shoppers were conducted in three independent Dutch representative samples of on- and off-premise alcohol outlets in 2013 (T0), 2014 (T1), and 2016 (T2). The effect of the policy change was estimated controlling for gender and age of the vendor. RESULTS: Mean alcohol sellers' compliance rates significantly increased for 15-year-olds from 46.5% before to 55.7% one year and to 73.9% two years after the policy change. Two years after the policy change, alcohol vendors were up to 3 times more likely to comply with the alcohol age limit policy. CONCLUSION: After the policy change, mean alcohol compliance rates significantly increased when 15-year-olds attempted to purchase alcohol, an effect which seems to increase over time. Nevertheless, a rise in the compliance rate was already present in the years preceding the introduction of the new minimum legal age. This perhaps signifies a process in which a lowering in the general acceptability of juvenile drinking already started before the increased minimum legal age was introduced and alcohol vendors might have been anticipating this formal legal change.

Physicians' Compliance with a Clinical Decision Support System Alerting during the Prescribing Process.

Clinical decision support systems have been shown to improve practitioner performance. Most systems designed to prevent medication errors generate lists with patients who fulfill the criteria of the algorithm. These lists are reviewed by a pharmacist and physicians are contacted by telephone. Presenting pop-up alerts as part of the workflow with a clear recommendation is a feature critical to success. Therefore we implemented three algorithms in a clinical decision support system alerting during the medication ordering process. We analyzed whether the recommendations in these alerts were followed. We evaluated 1. whether folic or folinic acid was co-prescribed more frequently within 48 h after ordering methotrexate, 2. whether vitamin D or analogues were co-prescribed more frequently within 48 h after ordering bisphophonates and 3. whether sodium lowering drugs were stopped more frequently within one hour in patients with hyponatremia. We analyzed the difference in the 48 days before implementation and the 43 days after implementation, using Pearson's Chi2 test. Co-prescription of folic or folinic acid increased from 54 to 91% (p = 0.014), co-prescription of vitamin D or analogues increased from 11 to 40% (p = 0.001) and the number of stopped orders for sodium lowering drugs increased from 3 to 14% (p = 0.002). This clinical decision support system that alerts physicians for preventable medication errors during the medication ordering process is an effective approach to improve prescribing behavior.