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1.
Public Health ; 180: 136-140, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31901574

RESUMEN

OBJECTIVES: To investigate patient demographics and venue type preferences within community settings associated with re-attendance for chlamydia testing. STUDY DESIGN: Data used for this analysis were obtained from the English National Chlamydia Screening Programme (NCSP) which focuses on prevention, control and treatment of chlamydia in sexually active under-25 year olds. A greater understanding of how young adults attend services helps to inform commissioners regarding where to focus resources within community settings. METHODS: Data from the Chlamydia surveillance system (CTAD) were used to count patient attendances at non-specialist sexual health services (SHSs) among 15-24-year-olds and monitor re-attendance for chlamydia testing within and between community services between 6 and 18 months of their first visit. RESULTS: From January 2013 to December 2016, 866,847 young people underwent 1,041,245 tests for chlamydia. Re-attendance for chlamydia testing was 20.1% (174,398/866,847). Re-attendance rate was 28.5% after a positive test and 19.5% after a negative test. For re-attenders, 64.2% used the same venue type for both visits. General practice (GP) and sexual and reproductive health services (SRH) were the most commonly re-attended services (31.0% and 30.6% respectively). CONCLUSIONS: Only one in five re-attended for chlamydia testing. Re-attendance was associated with having a positive result, accessibility and convenience. Patients are likely to return for testing to services they know. This should be considered by commissioners implementing new re-attendance guidance based on the NCSP.


Asunto(s)
Infecciones por Chlamydia/prevención & control , Servicios de Salud Comunitaria/estadística & datos numéricos , Utilización de Instalaciones y Servicios/estadística & datos numéricos , Tamizaje Masivo/estadística & datos numéricos , Adolescente , Infecciones por Chlamydia/epidemiología , Inglaterra/epidemiología , Femenino , Medicina General/estadística & datos numéricos , Humanos , Masculino , Programas Nacionales de Salud , Servicios de Salud Reproductiva/estadística & datos numéricos , Adulto Joven
2.
Int J Equity Health ; 18(1): 187, 2019 12 02.
Artículo en Inglés | MEDLINE | ID: mdl-31791347

RESUMEN

BACKGROUND: Horizontal equity in access to public general practitioner (GP) services by socioeconomic group has been addressed econometrically by testing the statement "equal probability of using public GP services for equal health care needs, regardless of socioeconomic status". Based on survey data, the conventional approach has been to estimate binomial econometric models in which when the respondent reports having visited a public GP, it counts as 1, otherwise it counts as 0. This is what we call a compartmentalised approach. Those respondents who did not visit a public GP but visited instead another doctor (specialist or private GP) would count as 0 (despite having used instead other modes of health care), thus conclusions of the compartmentalised approach might be biased. In such cases, a multinomial econometric model -that we called comprehensive approach- would be more appropriate to analyse horizontal equity in access to public GP services. The objective of this paper is to test for this potential bias by comparing a compartmentalised and a comprehensive approach, when analysing horizontal equity in access to public GP. METHODS: Using data from the 2016/17 Spanish National Health Survey, we estimate the probability of visiting a public GP as determined by socioeconomic status, health care need and demographic characteristics. We use binomial and multinomial logit and probit models in order to highlight the potential differences in the conclusions regarding socioeconomic inequities in access to public GP services. Socioeconomic status is proxied by education level, social class and employment situation. RESULTS: Our results show that conclusions are sensitive to the approach selected. Particularly, the horizontal inequity favouring individuals with lower education that resulted from the compartmentalised approach disappears under a comprehensive approach and only a social class effect remains. CONCLUSION: An analysis of horizontal equity in access to a particular health care service (like public GP services) undertaken following a compartmentalised approach should be compared with a comprehensive approach in order to test that there is no bias as a consequence of considering as zeros the utilisation of other types of health care.


Asunto(s)
Medicina General/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Sector Público/estadística & datos numéricos , Clase Social , Adolescente , Adulto , Anciano , Sesgo , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , España , Adulto Joven
3.
BMC Health Serv Res ; 19(1): 941, 2019 Dec 05.
Artículo en Inglés | MEDLINE | ID: mdl-31805930

RESUMEN

BACKGROUND: The organisation of cancer follow-up is under scrutiny in many countries, and general practice is suggested to become more involved. A central focus is timely detection of recurring previous cancer and new second primary cancer. More knowledge on the patient pathway before cancer recurrence and second primary cancer is warranted to ensure the best possible organisation of follow-up. We aimed to describe the healthcare utilisation in the year preceding a diagnosis of cancer recurrence or second primary cancer. METHODS: This nationwide register study comprises patients diagnosed with bladder, breast, colorectal, endometrial, lung, malignant melanoma and ovarian cancer in Denmark in 2008-2016. The frequency of healthcare contacts during the 12 months preceding a cancer recurrence or second primary cancer was estimated and compared to the frequency of cancer survivors in cancer remission. The main analyses were stratified on sex and healthcare setting. Furthermore, two sub-analyses were stratified on 1) sex, healthcare setting and age group and on 2) sex, healthcare setting and comorbidity status. RESULTS: The study population consisted of 7832 patients with recurrence and 2703 patients with second primary cancer. On average, the patients were in contact with general practice one time per month in the 12th month preceding a new cancer diagnosis (recurrence or second primary cancer). Increasing contact rates were seen from 7 months before diagnosis in general practice and from 12 months before diagnosis in hospitals. This pattern was more pronounced in patients with cancer recurrence, younger patients and patients with no comorbidity. For instance, the contact rate ratios for hospital contacts in non-comorbid women with recurrence demonstrated 30% more contacts in the 12th month before recurrence and 127% more contacts in the 2nd month before recurrence. CONCLUSIONS: The results show that cancer survivors are already seen in general practice on a regular basis. The increasing contact rates before a diagnosis of cancer recurrence or second primary cancer indicate that a window of opportunity exists for more timely diagnosis; this is seen in both general practice and in hospitals. Thus, cancer survivors may benefit from improvements in the organisation of cancer follow-up.


Asunto(s)
Medicina General/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Recurrencia Local de Neoplasia/terapia , Neoplasias Primarias Secundarias/terapia , Aceptación de la Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Dinamarca , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/diagnóstico , Neoplasias Primarias Secundarias/diagnóstico , Sistema de Registros , Adulto Joven
4.
N Z Med J ; 132(1488): 21-27, 2019 01 18.
Artículo en Inglés | MEDLINE | ID: mdl-31851658

RESUMEN

BACKGROUND: Urinalysis performed by dipstick testing is an aid to diagnosing urinary tract infections (UTI), and a tool in selecting patients who require urine culture and antibiotic treatment. Previous studies have demonstrated that UTI, especially in the elderly, are over-diagnosed and over-treated. We sought to study the pattern and yield of urinalysis and urine culture at our service in a tertiary institution. METHODS: A convenience sampling method was utilised to prospectively collect clinical data, through a pre-designed pro forma, from patients admitted to the General Medicine service at Christchurch Hospital between March and June 2016. RESULTS: The study included 395 patients, with a median age of 76 (range 15-100 years). The presence of urinary tract symptoms was documented in 94 patients (24%) and a non-specific syndrome of elevated temperature, confusion or subjective feverishness in 69 (17%). In symptomatic patients, 121 (74%) had a dipstick performed and 104 (86%) urine samples cultured. In the remaining patients, 181 (78%) had a dipstick performed and 81 (35%) had a urine sample sent for culture. CONCLUSIONS: We found a large number of urine dipsticks is being ordered unnecessarily in asymptomatic patients. A more useful test is urine microscopy and culture that is done on symptomatic patients only following careful clinical evaluation. Performing 'routine' urinalysis in patients presenting a wide variety of symptoms may lead to unnecessary urine cultures and treatment of asymptomatic bacteriuria. Efforts to reduce unnecessary tests and antibiotic treatment are a vital component of diagnostic stewardship programmes.


Asunto(s)
Medicina General/estadística & datos numéricos , Urinálisis/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Estudios Prospectivos , Procedimientos Innecesarios/estadística & datos numéricos , Infecciones Urinarias/diagnóstico , Infecciones Urinarias/epidemiología , Adulto Joven
6.
Scand J Prim Health Care ; 37(4): 452-458, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31709880

RESUMEN

Objective: It is generally expected that the growth of the older population will lead to an increase in the use of health care services. The aim was to examine the changes in the number of visits made to general practitioners (GP) by the older age groups, and whether such changes were associated with changes in mortality rates.Design and setting: A register-based observational study in a Finnish city where a significant increase in the older population took place from 2003 to 2014. The number of GP visits made by the older population was calculated, the visits per person per year in two-year series, together with respective mortality rates.Subjects: The study population consisted of inhabitants aged 65 years and older (65+) in Vantaa that visited a GP in primary health care.Main outcome measures: The number of GP visits per person per year in the whole older population during the study years.Results: In 2009-2010, there was a sudden drop in GP visits per person in the younger (65-74 years) age groups examined. In the population aged 85+, use of GP visits remained at a fairly constant level. The mortality rate decreased until the year 2008. After that, the positive trend ended and the mortality rate plateaued.Conclusions: Simultaneously with the decline in GP visits per person in the older population, the mortality rate leveled off from its positive trend in 2009-2010. Factors identified being associated with the number of GP consultations were organizational changes in primary health care, economic recession causing retrenchment, and even vaccinations during the swine flu epidemic.Key pointsAlong with an increasingly ageing population, concern over the supply of publicly funded health care has become more pronounced.The amount of GP visits of 65+ decreased in primary health care, especially in the youngest groups.However, in the oldest age groups (85+), the use of GPs remained unchanged regardless of changes in service supply.As the rate of GP visits among the population of 65+ declined, the positive trend in the mortality rate ceased.


Asunto(s)
Medicina General/estadística & datos numéricos , Mortalidad/tendencias , Visita a Consultorio Médico/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Distribución por Edad , Anciano , Anciano de 80 o más Años , Envejecimiento , Recesión Económica/estadística & datos numéricos , Femenino , Finlandia , Humanos , Masculino , Distribución por Sexo
8.
Presse Med ; 48(11 Pt 1): e293-e306, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31734050

RESUMEN

BACKGROUND: Little is known regarding healthcare for cancer patients treated mainly at home during the month before they die. The aim of this study was to provide information on how they were treated and what were their causes of death. METHODS: This population-based observational study analysing information obtained from the French national healthcare data system (SNDS) included adult health insurance beneficiaries treated for cancer who died in 2015 after having spent at least 25 of their last 30 days at home. RESULTS: Among the cancer patients who died in 2015, 25,463 (20%) were included [mean age (±SD) 74±13.2 years, men 62%]; 54% of them died at home. They were slightly older (75 vs. 73 years) than those who died in hospital, had less frequently received hospital palliative care during the year preceding their deaths (19% vs. 41%) and had less often used medical transport (41% vs. 73%) to an emergency department (8% vs. 62%), to hospital-based (11% vs. 17%) or community-based (16% vs. 12%) chemotherapy, to a general practitioner (73% vs. 78%) or to a community-based nursing service (63% vs. 73%). However, when they consulted a general practitioner (median 3 visits vs. 2) or a nurse (median 22 nursing procedures vs. 10) during their last month of life, visits were more frequent. The leading cause of death was tumour, which represented 69% of deaths at home vs. 74% of deaths in hospital. CONCLUSIONS: In France, home management during the last month of life is uncommon and even when it is occurs, in one out of two cases patients pass away in a hospital setting. This study is an interrogation on medical choices, given the wish of many of the French to die at home and placing their choices in an international perspective.


Asunto(s)
Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Atención Domiciliaria de Salud , Neoplasias/mortalidad , Neoplasias/terapia , Cuidado Terminal , Distribución por Edad , Factores de Edad , Anciano , Anciano de 80 o más Años , Causas de Muerte , Comorbilidad , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Francia , Medicina General/estadística & datos numéricos , Atención Domiciliaria de Salud/estadística & datos numéricos , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Servicios de Enfermería/estadística & datos numéricos , Cuidados Paliativos/estadística & datos numéricos , Estudios Retrospectivos , Distribución por Sexo , Factores de Tiempo , Transporte de Pacientes/estadística & datos numéricos
9.
N Z Med J ; 132(1506): 52-59, 2019 11 08.
Artículo en Inglés | MEDLINE | ID: mdl-31778372

RESUMEN

AIMS: To determine the career decision intentions of graduating doctors, and the relationship between these intentions and the predicted medical workforce needs in New Zealand in 10 years' time. METHODS: A workforce forecasting model developed by the Ministry of Health (MOH) has been used to predict the proportion of doctors required in each medical specialty in 2028 in New Zealand. The future work intentions of recently graduated doctors at the Universities of Auckland and Otago were collected from the Medical Student Outcomes Data (MSOD), and compared with these predicted needs. RESULTS: Between 2013 and 2017, 2,292 doctors graduated in New Zealand, of whom 1,583 completed the MSOD preferences section (response rate 69%). Of these only 50.1% had decided on a future medical specialty. The most popular were surgical specialties (26.2%), general practice (20.7%), and internal medicine (11.0%). Compared to the MOH workforce forecast model there appears to be insufficient interest in general practice at the time of graduation. CONCLUSIONS: To shape the medical workforce to meet forecast needs, multiple stakeholders will need to collaborate, with a special focus on the early postgraduate years, as many doctors have yet to decide on specialisation.


Asunto(s)
Empleo , Fuerza Laboral en Salud/tendencias , Médicos/provisión & distribución , Estudiantes de Medicina/estadística & datos numéricos , Adulto , Anciano , Selección de Profesión , Bases de Datos Factuales , Femenino , Medicina General/estadística & datos numéricos , Humanos , Medicina Interna/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Motivación , Nueva Zelanda , Especialidades Quirúrgicas/estadística & datos numéricos , Estudiantes de Medicina/psicología , Encuestas y Cuestionarios , Adulto Joven
10.
Ghana Med J ; 53(3): 204-209, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31741492

RESUMEN

Background: Several factors have been identified that influence physicians' prescribing habits. The influence of physician's specialty has not been studied. This study is to determine if there are differences in the prescribing patterns amongst these various specialities that run a general medicine clinic at a tertiary hospital in Ghana. Methods: Data collected from the out-patients clinic attendance records were analysed using WHO Rational Use of Medicines indicators. Analysis of Variance Test was carried out to establish if there was any variance in the prescribing indicators amongst 4 units of Physicians. Results: 678 patient encounters were utilised for this study. The average number of drugs prescribed per encounter was 4.4, drugs prescribed by generic name was 86.9%, patient encounters in which antibiotics prescribed were 6.5% (n= 44) and injections were prescribed in 3.2% (n=22) of patient encounters. 64.0% of all drugs prescribed were from the Ghanaian EML. The unit of the physician did not have a significant effect on the average number of medicines prescribed per patient encounter (F (3, 674) = 2.19, p = 0.088), and the percentage of medicines that were prescribed from the Essential Medicines List (F (3, 674) = 1.52, p = 0.207). The unit the physician belonged to however did have a significant effect at p < 0.05 on the prescription of generic medications (F (3, 674) = 4.79, p = 0.003). Conclusion: The physician units did not differ in their prescribing patterns at the general medicine clinic except for prescription of drugs by their generic names. Funding: None declared.


Asunto(s)
Instituciones de Atención Ambulatoria/estadística & datos numéricos , Actitud del Personal de Salud , Prescripciones de Medicamentos/estadística & datos numéricos , Medicina General/estadística & datos numéricos , Médicos Generales/psicología , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Ghana , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven
12.
BMJ ; 367: l5205, 2019 Oct 02.
Artículo en Inglés | MEDLINE | ID: mdl-31578187

RESUMEN

OBJECTIVES: To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions. DESIGN: Automated change detection in longitudinal prescribing data. SETTING: Prescribing data in English primary care. PARTICIPANTS: English general practices. MAIN OUTCOME MEASURES: In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)). RESULTS: Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI). CONCLUSIONS: Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.


Asunto(s)
Prescripciones de Medicamentos/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Evaluación de Procesos, Atención de Salud/métodos , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Medicina Estatal/estadística & datos numéricos , Antiinfecciosos/uso terapéutico , Conjuntos de Datos como Asunto , Sustitución de Medicamentos/estadística & datos numéricos , Medicamentos Genéricos/uso terapéutico , Inglaterra , Medicina General/organización & administración , Medicina General/normas , Medicina General/estadística & datos numéricos , Humanos , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Evaluación de Procesos, Atención de Salud/estadística & datos numéricos , Medicina Estatal/normas , Factores de Tiempo , Infecciones Urinarias/tratamiento farmacológico
13.
Dan Med J ; 66(10)2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31571572

RESUMEN

INTRODUCTION: In Denmark, diagnosing and treating allergy is mainly performed by general practitioners (GPs), but precise expectations of the GPs are not described in guidelines. Furthermore, very little is known about GPs' use of allergen-specific immunoglobulin E (sIgE) tests. The aim of this study was to describe the use of these tests in the Central Denmark Region. METHODS: We performed analyses on data from all sIgE tests ordered by GPs in the Central Denmark Region in 2015. A test was considered positive if the serum level of IgE was ≥ 0.35 kU/l. RESULTS: Serum levels of sIgE were determined in 26,129 patients, equivalent to 2% of the Danish population. A total of 106,237 tests were performed, the majority as part of screening algorithms for inhalant and food allergens. Screening was ordered 20,697 times for inhalation allergens and 12,999 times for food allergens. Additionally, a considerable number of tests for antibiotics (n = 4,407), insect venom (n = 748) and other allergens were performed (n = 824). Positive rates were determined for various allergens in relation to gender and age. The rates were generally higher than rates known to be present in the background population. A higher percentage of females than males was tested. However, positive rates were generally lower in females than in males. CONCLUSIONS: This is the first descriptive analysis of the use of testing for sIgE in general practice. Results from this study may be used to optimise how GPs order and interpret sIgE tests in the future. FUNDING: none. TRIAL REGISTRATION: not relevant.


Asunto(s)
Alérgenos/análisis , Medicina General/estadística & datos numéricos , Hipersensibilidad Inmediata/diagnóstico , Inmunoglobulina E/análisis , Pruebas Inmunológicas/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Alérgenos/inmunología , Dinamarca , Femenino , Humanos , Hipersensibilidad Inmediata/inmunología , Inmunoglobulina E/inmunología , Pruebas Inmunológicas/métodos , Masculino , Persona de Mediana Edad
14.
Int J Clin Pharm ; 41(5): 1138-1142, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31493208

RESUMEN

Background A 12-month pilot was implemented in two general practices in remote and rural Scotland, with patients referred by general practitioners to specialist mental health pharmacist independent prescribers. Objective The objective was to evaluate the pilot service from the perspectives of the patients and the care team. Methods The pharmacists routinely recorded patient-specific data of all clinical issues and their actions at the time of each consultation. Further datasets comprised baseline and follow-up Patient Health Questionnaire (PHQ-9) and/or Generalised Anxiety Disorder (GAD-7) rating scales, a patient survey and interviews with members of the care team. Results Of the 75 patients, two-thirds (n = 47, 62.7%) were referred with a diagnosis of mixed depression and anxiety. There were 324 consultations (median 3, IQR 2-5, range 1-14) and 181 prescribing actions. At pilot completion, 34 patients (45.3%) had PHQ-9 and/or GAD-7 scores reduced by 50%. Patient questionnaires and staff interviews generated positive responses. Conclusion This pilot has provided evidence that specialist mental health pharmacist independent prescribers delivered quality care to patients with diagnoses of moderate to severe depression and/or anxiety. Whilst accepting study limitations, there is potential to translate the pilot model of care to sustained services throughout general practice.


Asunto(s)
Prescripciones de Medicamentos , Medicina General/estadística & datos numéricos , Trastornos Mentales/tratamiento farmacológico , Farmacéuticos , Adulto , Anciano , Ansiedad/tratamiento farmacológico , Ansiedad/psicología , Trastornos de Ansiedad/tratamiento farmacológico , Trastornos de Ansiedad/psicología , Competencia Clínica , Depresión/tratamiento farmacológico , Depresión/psicología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Atención Primaria de Salud , Rol Profesional , Derivación y Consulta , Población Rural , Escocia , Encuestas y Cuestionarios , Adulto Joven
15.
Med Sci (Paris) ; 35(8-9): 674-681, 2019.
Artículo en Francés | MEDLINE | ID: mdl-31532380

RESUMEN

A placebo drug is defined as a treatment without any specific pharmacological efficacy, that works when the patient thinks to receive an active treatment, through a psychological and physiological mechanism. This study aimed to evaluate the use of placebo in French hospitals, in Polyvalent Medicine units. A questionnaire comprising 15 items was sent to 372 units. The analysis of 153 responses was conducted from dynamic crosstabs in Excel and using the R software available online. The survey confirmed that the use of placebos in hospital is frequent, with nearly 2/3 of professionals answering the questionnaire declared to use it. The oral capsule is the most commonly used form. Placebo is mainly administered at night, in case of pain, insomnia or anxiety, to so-called "difficult" patients. Placebo is not always given after medical prescription. In most cases, patients are not informed that they receive a placebo. The majority of professionals believed in the placebo effect but considered to be insufficiently informed and trained in the use of placebo in current practice. Although the placebo effect is now demonstrated, ethical and legal considerations recommend placebo treatment only on medical prescription, with the prior information of the patient. The placebo could be used as complementary therapy to conventional treatment in the cases of this therapeutic effectiveness has been demonstrated. Professionals should be trained in the use of placebo in order to avoid nocebo effect and potentiate beneficial effects of placebo.


Asunto(s)
Hospitales , Placebos/uso terapéutico , Adulto , Revelación/ética , Revelación/estadística & datos numéricos , Femenino , Francia/epidemiología , Medicina General/ética , Medicina General/métodos , Medicina General/estadística & datos numéricos , Unidades Hospitalarias/ética , Unidades Hospitalarias/normas , Unidades Hospitalarias/estadística & datos numéricos , Hospitales/ética , Hospitales/estadística & datos numéricos , Humanos , Masculino , Principios Morales , Relaciones Médico-Paciente , Efecto Placebo
16.
BMC Health Serv Res ; 19(1): 648, 2019 Sep 06.
Artículo en Inglés | MEDLINE | ID: mdl-31492139

RESUMEN

BACKGROUND: Commissioning innovative health technologies is typically complex and multi-faceted. Drawing on the negotiated order perspective, we explore the process by which commissioning organisations make their decisions to commission innovative health technologies. The empirical backdrop to this discussion is provided by a case study exploring the commissioning considerations for a new photoplethysmography-based diagnostic technology for peripheral arterial disease in primary care in the UK. METHODS: The research involved an empirical case study of four Clinical Commissioning Groups (CCGs) involved in the commissioning of services in primary and secondary care. Semi-structured in-depth interviews (16 in total) and two focus groups (a total of eight people participated, four in each group) were conducted with key individuals involved in commissioning services in the NHS including (i) senior NHS clinical leaders and directors (ii) commissioners and health care managers across CCGs and (iii) local general practitioners. RESULTS: Commissioning of a new diagnostic technology for peripheral arterial disease in primary care involves high levels of protracted negotiations over funding between providers and commissioners, alliance building, conflict resolution and compromise of objectives where the outcomes of change are highly contingent upon interventions made across different care settings. Our evidence illustrates how reconfigurations of inter-organisational relations, and of clinical and related work practices required for the successful implementation of a new technology could become the major challenge in commissioning negotiations. CONCLUSIONS: Innovative health technologies such as the diagnostic technology for peripheral arterial disease are commissioned in care pathways where the value of such technology is realised by those delivering care to patients. The detail of how care pathways are commissioned is complex and involves high degrees of uncertainty concerning such issues as prioritisation decisions, patient benefits, clinical buy-in, value for money and unintended consequences. Recent developments in the new care models and integrated care systems (ICSs) in the UK offer a unique opportunity for the successful commissioning arrangements of innovative health technologies in primary care such as the new diagnostic technology for peripheral arterial disease.


Asunto(s)
Tecnología Biomédica/estadística & datos numéricos , Medicina General/estadística & datos numéricos , Invenciones , Tecnología Biomédica/organización & administración , Difusión de Innovaciones , Grupos Focales , Medicina General/organización & administración , Médicos Generales/organización & administración , Médicos Generales/estadística & datos numéricos , Administración de los Servicios de Salud , Humanos , Negociación , Atención Primaria de Salud/organización & administración , Atención Primaria de Salud/estadística & datos numéricos , Medicina Estatal
17.
BMC Fam Pract ; 20(1): 126, 2019 09 09.
Artículo en Inglés | MEDLINE | ID: mdl-31500585

RESUMEN

BACKGROUND: In the UK, there is ongoing integration of pharmacists into general practice as a new healthcare service in primary care. Evaluation of the service involves national measures that require pharmacists to record their work, on the general practice clinical computer systems, using electronic activity codes. No national agreement, however, has been established on what activities to record. The purpose of this study was to attempt to reach consensus on what activities general practice-based pharmacists should record. METHODS: The e-Delphi method was chosen as it is an excellent technique for achieving consensus. The study began with an initial stage in which screening of a general practice clinical computer system and discussion groups with pharmacists from two 'pharmacists in general practice' sites identified 81 codes potentially relevant to general practice-based pharmacists' work. Twenty-nine experts (pharmacists and pharmacy technicians from the two sites along with experts recruited through national committees) were then invited by e-mail to participate as a panel in three e-Delphi questionnaire rounds. In each round, panellists were asked to grade or rank codes and justify their choices. In every round, panellists were provided with anonymised feedback from the previous round which included their individual choices along with their co-panellists' views. Final consensus (in Round 3) was defined as at least 80% agreement. Commentaries on the codes from all e-Delphi rounds were pooled together and analysed thematically. RESULTS: Twenty-one individual panellists took part in the study (there were 12 responses in Round 1, 18 in Round 2 and 16 in Round 3). Commentaries on the codes included three themes: challenges and facilitators; level of detail; and activities related to funding. Consensus was achieved for ten codes, eight of which related to activities (general and disease specific medication reviews, monitoring of high-risk drugs and medicines reconciliation) and two to patient outcomes (presence of side effects and satisfactory understanding of medication). CONCLUSIONS: A formal consensus method revealed general practice-based pharmacists' preferences for activity coding. Findings will inform policy so that any future shaping of activity coding for general practice-based pharmacists takes account of pharmacists' actual needs and preferences.


Asunto(s)
Codificación Clínica , Medicina General , Farmacéuticos , Codificación Clínica/métodos , Codificación Clínica/normas , Consenso , Técnica Delfos , Medicina General/estadística & datos numéricos , Humanos , Farmacéuticos/estadística & datos numéricos , Rol Profesional , Encuestas y Cuestionarios , Reino Unido
18.
J Autism Dev Disord ; 49(12): 4919-4928, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-31473948

RESUMEN

Knowledge about the quality of care delivered to children with autism spectrum disorders (ASD) in relation to that recommended by clinical practice guidelines (CPGs) is limited. ASD care quality indicators were developed from CPGs and validated by experts, then used to assess the quality of care delivered by general practitioners (GPs) and pediatricians in Australia. Data were retrospectively collected from the medical records of 228 children (≤ 15 years) with ASD for 2012-2013. Overall quality of care was high, but with considerable variation among indicators, and between GPs and pediatricians-e.g., GPs were less likely to complete the assessment care bundle (61%; 95% CI 21-92). Findings highlight potential areas for improvement in the need for standardized criteria for diagnosis.


Asunto(s)
Trastorno del Espectro Autista/terapia , Medicina General/normas , Calidad de la Atención de Salud , Australia , Trastorno del Espectro Autista/diagnóstico , Trastorno del Espectro Autista/epidemiología , Niño , Preescolar , Femenino , Medicina General/estadística & datos numéricos , Humanos , Masculino , Registros Médicos/estadística & datos numéricos
19.
Ir Med J ; 112(5): 932, 2019 05 09.
Artículo en Inglés | MEDLINE | ID: mdl-31411014

RESUMEN

Aim Proton pump inhibitors (PPIs) are amongst the most frequently prescribed medicines. Evidence to date shows these are being inappropriately overprescribed. Although highly effective, PPIs are increasingly recognized to be associated with many adverse health outcomes. The aims of this study are to assess the extent and quality of PPI prescribing in an urban general practice. Method Retrospective chart review and descriptive analysis of all prescriptions issued over one month was undertaken to determine the frequency and duration of PPI use, the likely indications and results of endoscopic findings. Results PPIs represented 20% of all prescriptions issued in June 2017, of which 80% were on long-term therapy. Esomeprazole use prevailed. Low dose therapy was least frequently prescribed (7%) compared with high dose therapy (93%). PPI use increased with age, and duration of therapy was prolonged for greater than one year in the majority of patients. Patients were commenced therapy without clear indication in 40% of cases. Findings of endoscopic evaluation in 58 (64%) patients suggest PPI therapy was inappropriately continued in the majority of cases (81%). Conclusion Chronic inappropriate overprescribing of PPIs remains a concern and contribute potentially to patient harm and wasteful financial resources. The ongoing need to optimise PPI prescribing remains paramount. Clinicians are encouraged to prescribe judiciously and in accordance with evidence-based guidelines.


Asunto(s)
Medicina General/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Inhibidores de la Bomba de Protones/uso terapéutico , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Endoscopía Gastrointestinal/estadística & datos numéricos , Femenino , Humanos , Prescripción Inadecuada/estadística & datos numéricos , Irlanda , Masculino , Persona de Mediana Edad , Inhibidores de la Bomba de Protones/administración & dosificación , Estudios Retrospectivos , Adulto Joven
20.
Med Decis Making ; 39(7): 805-815, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31423911

RESUMEN

Background. Patient decision aids (PtDAs) are effective interventions to support patient involvement in health care decisions, but there is little use in practice. Our study aimed to determine subsequent PtDA use in clinical practice following published randomized controlled trials. Design. A descriptive study using an e-mail-embedded questionnaire survey targeting authors of 133 trials included in Cochrane Reviews of PtDAs (106 authors). We classified PtDA level of use as a) implementation, defined as integrating within care processes; b) dissemination to target users with planned strategies; and c) diffusion, defined as passive, unplanned spread. We conducted content analysis to identify barriers and enablers guided by the Ottawa Model of Research Use. Results. Ninety-eight authors responded (92.5%) on 108 trialed PtDAs. Reported levels of use were implementation (n = 29; 28%), dissemination to target user(s) (n = 9; 9%), and diffusion (n = 7; 7%); 57 (55%) reported no uptake, and 1 had no response (1%). Barriers to use in clinical practice were identified at the level of researchers (e.g., lack of posttrial plan), PtDAs (e.g., outdated, delivery mechanism), clinicians (e.g., disagreed with PtDA use), and practice environment (e.g., infrastructure support; funding). Enablers were online delivery, organizational endorsement (e.g., professional organization, charity, government), and design for and integration into the care process. Limitations. Self-report bias and potential for recall bias. Conclusions. Only 44% of PtDA trial authors indicated some level of subsequent use following their trial. The most commonly reported barriers were lack of funding, outdated PtDAs, and clinician disagreement with PtDA use. To improve subsequent use, researchers should codesign PtDAs with end users to ensure fit with clinical practice and develop an implementation plan. National systems (e.g., platforms, endorsement, funding) can enable use.


Asunto(s)
Técnicas de Apoyo para la Decisión , Medicina General/estadística & datos numéricos , Difusión de la Información , Educación del Paciente como Asunto/estadística & datos numéricos , Participación del Paciente , Humanos , Educación del Paciente como Asunto/economía , Educación del Paciente como Asunto/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto
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