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2.
Rev Med Suisse ; 16(678): 117-122, 2020 Jan 22.
Artigo em Francês | MEDLINE | ID: mdl-31967753

RESUMO

In healthy adults, vitamin D does not prevent falls or hip fractures. The diabetogenic effect of topical steroids is significant and dose dependent. Pulmonary embolism can be surely ruled out by the YEARS algorithm adapted to pregnancy. Patients with osteoarthritis treated with tramadol have a higher risk of death when compared to those treated with non-steroidal anti-inflammatory drugs. Inappropriate prescribing in elderly patients can be reduced by an educational intervention deployed in pharmacies. Medical scribes are effective in improving visit quality and job satisfaction of family physicians. Impedance studies lead to new diagnostic approaches in chronic fatigue. In healthy individuals, isolated check-up interventions do not have an impact on morbidity and mortality.


Assuntos
Medicina Geral , Medicina Interna , Osteoartrite , Adulto , Idoso , Anti-Inflamatórios não Esteroides , Humanos , Prescrição Inadequada , Medicina Interna/tendências , Osteoartrite/tratamento farmacológico
4.
BMJ Open Qual ; 8(4): e000670, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31673642

RESUMO

Background: Guidelines recommend primary care physicians (PCPs) offer patients a choice between colonoscopy and faecal immunochemical test (FIT) for colorectal cancer (CRC) screening. Patients choose almost evenly between both tests but in Switzerland, most are tested with colonoscopy while screening rates are low. A quality circle (QC) of PCPs is an ideal site to train physicians in shared decision-making (SDM) that will help more patients decide if they want to be tested and choose the test they prefer. Objective: Systematically assess CRC screening status of eligible 50-75 y.o. patients and through SDM increase the proportion of patients who have the opportunity to choose CRC screening and the test (FIT or colonoscopy). Methods: Working through four Plan-Do-Study-Act (PDSA) cycles in their QC, PCPs adapted tools for SDM and surmounted organisational barriers by involving practice assistants. Each PCP included 20, then 40 consecutive 50-75 y.o. patients, repeatedly reported CRC status as well as the proportion of eligible patients with whom CRC screening could be discussed and patients' decisions. Results: 9 PCPs initially included 176, then 320 patients. CRC screening status was routinely noted in the electronic medical record and CRC screening was implemented in daily routine, increasing eligible patients' chance to be offered screening. Over a year, screening rates trended upwards, from 37% to 40% (p=0.46) and FIT use increased (2%-7%, p=0.008). Initially, 7/9 PCPs had no patient ever tested with FIT; after the intervention, only 2/8 recorded no FIT tests. Conclusions: Through data-driven PDSA cycles and significant organisational changes, PCPs of a QC systematically collected data on CRC screening status and implemented SDM tools in their daily routine. This increased patients' chance to discuss CRC screening. The more balanced use of FIT and colonoscopy suggests that patients' values and preferences were better respected.

5.
Rev Med Suisse ; 15(669): 1968-1971, 2019 Oct 30.
Artigo em Francês | MEDLINE | ID: mdl-31663696

RESUMO

We have been studying multimorbidity in epidemiology and clinical practice since the 1970s. Growing experience shows that the concept of multimorbidity is helpful for epidemiologists to describe population-level changes, but of little use to patients and clinicians who 'diagnose' multimorbidity. Several large, rigorous clinical trials show that organizational changes in primary care can improve the care of these complex patients, but do not improve directly health-related quality of life. This article describes the history of multimorbidity and results of recent randomized trials to prompt a discussion of new approaches to improve the experience of people living with multiple chronic diseases.


Assuntos
Doença Crônica , Multimorbidade/tendências , Atenção Primária à Saúde/métodos , Doença Crônica/epidemiologia , Doença Crônica/terapia , Humanos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
8.
Am J Gastroenterol ; 114(11): 1795-1801, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31658130

RESUMO

OBJECTIVES: Several recent studies have reported very high estimates of sensitivity and specificity of fecal immunochemical tests (FITs) at seemingly high levels of precision using registry-based follow-up of participants in very large FIT-based screening programs. We aimed to assess the validity of estimates of diagnostic performance parameters derived by this indirect approach. METHODS: We modeled expected values of sensitivity and specificity of colorectal cancer detection in studies using the indirect approach and their deviation from true values under a broad range of plausible assumptions, and we compared these expected values with recently reported estimates of FIT sensitivity and specificity from such studies. RESULTS: Using a sensitivity of 75% and specificity of 93.6% (from studies using a direct approach, i.e., colonoscopy follow-up of all participants), the indirect approach would be expected to yield sensitivities between 84.5% and 91.1% and specificities between 93.4% and 93.6% under a range of realistic assumptions regarding colonoscopic follow-up rates of positive FITs and clinical manifestation rates of preclinical colorectal cancer. DISCUSSION: Very high sensitivities of FITs recently reported with seemingly very high levels of precision by several large-scale registry-based studies, which are in line with expected results based on our model calculations, are likely to be strongly overestimated and need to be interpreted with due caution.

9.
Gastroenterology ; 157(6): 1494-1505, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31472152

RESUMO

BACKGROUND & AIMS: Quantitative fecal immunochemical tests (FITs) for hemoglobin are commonly used for colorectal cancer (CRC) screening. We aimed to quantify the change in CRC and advanced adenoma detection and number of positive test results at different positivity thresholds and by sex and age. METHODS: We searched MEDLINE and EMBASE, selecting articles of FIT for CRC detection in asymptomatic adults undergoing screening. We calculated sensitivity and specificity, as well as detected number of cancers, advanced adenomas, and positive test results at positivity thresholds ≤10 µg hemoglobin/g feces, 10 to ≤20 µg/g, 20 to ≤30 µg/g, and >30 µg/g. We also analyzed results from stratified by patient sex, age, and reference standard. RESULTS: Our meta-analysis comprised 46 studies with 2.4 million participants and 6478 detected cancers. Sensitivity for detection of CRC increased from 69% (95% confidence interval [CI], 63%-75%) at thresholds >10 µg/g and ≤20 µg/g to 80% (95% CI, 76%-83%) at thresholds ≤10 µg/g. At these threshold values, sensitivity for detection of advanced adenomas increased from 21% (95% CI, 18%-25%) to 31% (95% CI, 27%-35%), whereas specificity decreased from 94% (95% CI, 93%-96%) to 91% (95% CI, 89%-93%). In 3 studies stratified by sex, sensitivity of CRC detection was 77% in men (95% CI, 75%-79%) and 81% in women (95% CI, 60%-100%) (P = .68). In 3 studies stratified by age groups, sensitivity of CRC detection was 85% for ages 50-59 years (95% CI, 71%-99%) and 73% for ages 60-69 years (95% CI, 71%-75%) (P = .10). All studies with colonoscopy follow-up had similar sensitivity levels for detection of CRC to studies that analyzed 2-year registry follow-up data (74%; 95% CI, 68%-78% vs 75%; 95% CI, 73%-77%). CONCLUSIONS: In a meta-analysis of studies that analyzed detection of CRC and advanced adenomas at different FIT positivity thresholds, we found the sensitivity and specificity of detection to vary with positive cutoff value. It might be possible to decrease positive threshold values for centers with sufficient follow-up colonoscopy resources. More research is needed to precisely establish FIT thresholds for each sex and age subgroup. PROTOCOL: PROSPERO CRD42017068760.


Assuntos
Adenoma/diagnóstico , Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/normas , Programas de Rastreamento/normas , Sangue Oculto , Fatores Etários , Colonoscopia , Detecção Precoce de Câncer/métodos , Hemoglobinas/análise , Humanos , Programas de Rastreamento/métodos , Padrões de Referência , Sensibilidade e Especificidade , Fatores Sexuais
11.
Int J Public Health ; 64(7): 1075-1083, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31201428

RESUMO

OBJECTIVES: To determine the proportion of 50-75-year-old patients who visit a primary care physician's (PCP) office and were tested for colorectal cancer (CRC) by either colonoscopy within 10 years or fecal occult blood testing (FOBT) within 2 years. To describe the variation in care between PCPs and factors associated with these proportions. METHODS: Cross-sectional data collected between April and December 2017. PARTICIPANTS: PCPs reporting for the Swiss Sentinel Surveillance Network. Each PCP collected demographic data and CRC testing status from 40 consecutive patients. MEASUREMENTS: proportions of patients up to date with CRC screening and method used (colonoscopy/FOBT/Other); variation in the outcome measures between PCPs; association of physician-level factors with main outcomes. RESULTS: 91/129 PCPs collected data from 3451 patients; 45% had been tested for CRC within recommended intervals (41% colonoscopy, 4% FOBT). The proportions of patients tested and testing with colonoscopy versus FOBT varied widely between PCPs. Language region was associated with PCPs' rate of FOBT prescription. CONCLUSIONS: Less than half of patients who visited PCPs in Switzerland were tested for CRC within recommended intervals. PCPs varied widely in their testing practices.


Assuntos
Neoplasias Colorretais/diagnóstico , Detecção Precoce de Câncer/estatística & dados numéricos , Médicos de Atenção Primária/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Idoso , Colonoscopia , Estudos Transversais , Detecção Precoce de Câncer/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sangue Oculto , Suíça
13.
Rev Med Suisse ; 15(651): 1044, 2019 May 15.
Artigo em Francês | MEDLINE | ID: mdl-31091041
14.
BMJ Open Qual ; 8(1): e000452, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30997416

RESUMO

Colorectal cancer (CRC) cancer screening uptake is low in our diverse, outpatient teaching clinic. A state-level public screening programme was recently launched that provides faecal immunochemical tests or screening colonoscopy to all citizens aged 50-69 years via mailed invitations, with the possibility of earlier, opportunistic inclusion. Mailed outreach is expected to be rolled out over the next 5 years. In the interim, we aimed to increase CRC screening by accelerating the inclusion of patients into the programme by implementing a provider feedback programme with residents. We used billing reports to define the eligible target population and monthly lists of included patients to track progress. All residents received a standard intervention that provided basic training and communication tools facilitating shared decision making in CRC screening decisions. We then developed and implemented the intervention over 3 Plan-Do-Study-Act cycles in 2 of 4 groups of residents, each with 7 residents and approximately 250 eligible patients. The intervention consisted of individualised reports on the proportion of each resident's patients that had been included in the screening programme and the names of patients who had not yet been included. The first group that received the intervention had included 58 of 232 eligible patients (25%) at 8 months after the feedback intervention and the second group 51 of 249 eligible patients (20%) at 4 months. In comparison, the 2 groups with only the standard intervention had included 32 of 252 (13%) and 27 of 260 (10%) of their patients, respectively, at 11 months after the baseline intervention. These results suggest that provider feedback to medical residents can promote resident self-awareness and increase the proportion of patients included in a public programme when provided in addition to educational interventions.

15.
Cochrane Database Syst Rev ; 3: CD004705, 2019 03 26.
Artigo em Inglês | MEDLINE | ID: mdl-30912847

RESUMO

BACKGROUND: A possible strategy for increasing smoking cessation rates could be to provide smokers with feedback on the current or potential future biomedical effects of smoking using, for example, measurement of exhaled carbon monoxide (CO), lung function, or genetic susceptibility to lung cancer or other diseases. OBJECTIVES: The main objective was to determine the efficacy of providing smokers with feedback on their exhaled CO measurement, spirometry results, atherosclerotic plaque imaging, and genetic susceptibility to smoking-related diseases in helping them to quit smoking. SEARCH METHODS: For the most recent update, we searched the Cochrane Tobacco Addiction Group Specialized Register in March 2018 and ClinicalTrials.gov and the WHO ICTRP in September 2018 for studies added since the last update in 2012. SELECTION CRITERIA: Inclusion criteria for the review were: a randomised controlled trial design; participants being current smokers; interventions based on a biomedical test to increase smoking cessation rates; control groups receiving all other components of intervention; and an outcome of smoking cessation rate at least six months after the start of the intervention. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We expressed results as a risk ratio (RR) for smoking cessation with 95% confidence intervals (CI). Where appropriate, we pooled studies using a Mantel-Haenszel random-effects method. MAIN RESULTS: We included 20 trials using a variety of biomedical tests interventions; one trial included two interventions, for a total of 21 interventions. We included a total of 9262 participants, all of whom were adult smokers. All studies included both men and women adult smokers at different stages of change and motivation for smoking cessation. We judged all but three studies to be at high or unclear risk of bias in at least one domain. We pooled trials in three categories according to the type of biofeedback provided: feedback on risk exposure (five studies); feedback on smoking-related disease risk (five studies); and feedback on smoking-related harm (11 studies). There was no evidence of increased cessation rates from feedback on risk exposure, consisting mainly of feedback on CO measurement, in five pooled trials (RR 1.00, 95% CI 0.83 to 1.21; I2 = 0%; n = 2368). Feedback on smoking-related disease risk, including four studies testing feedback on genetic markers for cancer risk and one study with feedback on genetic markers for risk of Crohn's disease, did not show a benefit in smoking cessation (RR 0.80, 95% CI 0.63 to 1.01; I2 = 0%; n = 2064). Feedback on smoking-related harm, including nine studies testing spirometry with or without feedback on lung age and two studies on feedback on carotid ultrasound, also did not show a benefit (RR 1.26, 95% CI 0.99 to 1.61; I2 = 34%; n = 3314). Only one study directly compared multiple forms of measurement with a single form of measurement, and did not detect a significant difference in effect between measurement of CO plus genetic susceptibility to lung cancer and measurement of CO only (RR 0.82, 95% CI 0.43 to 1.56; n = 189). AUTHORS' CONCLUSIONS: There is little evidence about the effects of biomedical risk assessment as an aid for smoking cessation. The most promising results relate to spirometry and carotid ultrasound, where moderate-certainty evidence, limited by imprecision and risk of bias, did not detect a statistically significant benefit, but confidence intervals very narrowly missed one, and the point estimate favoured the intervention. A sensitivity analysis removing those studies at high risk of bias did detect a benefit. Moderate-certainty evidence limited by risk of bias did not detect an effect of feedback on smoking exposure by CO monitoring. Low-certainty evidence, limited by risk of bias and imprecision, did not detect a benefit from feedback on smoking-related risk by genetic marker testing. There is insufficient evidence with which to evaluate the hypothesis that multiple types of assessment are more effective than single forms of assessment.


Assuntos
Biorretroalimentação Psicológica/métodos , Monóxido de Carbono/análise , Abandono do Hábito de Fumar/psicologia , Fumar/efeitos adversos , Adulto , Testes Respiratórios , Feminino , Predisposição Genética para Doença , Humanos , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco/métodos , Fumar/genética , Fumar/metabolismo , Abandono do Hábito de Fumar/métodos , Abandono do Hábito de Fumar/estatística & dados numéricos , Espirometria
16.
Dig Dis Sci ; 64(9): 2489-2496, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30915656

RESUMO

Mailed outreach promoting colorectal cancer (CRC) screening with a stool blood test kit may increase participation, but magnitude and consistency of benefit of this intervention strategy is uncertain. Our aim was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing mailed outreach offering stool tests to usual care, clinic-based screening offers on CRC screening uptake in the USA. We performed a systematic literature search of five databases for RCTs of mailed outreach from January 1980 through June 2017. Primary outcome was screening completion, summarized using random-effects meta-analysis as pooled differences in proportion completing the screening and relative risk of achieving screening compared to control. Subgroup analyses by test type offered-fecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT), the presence of telephone reminders, and the presence of predominant underserved/minority population within study were performed. Quality of evidence was evaluated using the GRADE framework. Seven RCTs which enrolled 12,501 subjects were included (n = 5703 assigned mailed outreach and n = 6798 usual care). Mailed outreach resulted in a 28% absolute (95% CI 25-30%; I2 = 47%) and a 2.8-fold relative (RR 2.65, 95% CI 2.03-3.45; I2 = 92%) increase in screening completion compared to usual care, with a number needed to invite estimated to be 3.6. Similar outcomes were observed across subgroups. Overall body of evidence was at moderate quality. Mailed outreach offering a gFOBT or FIT is associated with a large and consistent increase in CRC screening completion and should be considered for more widespread implementation for improving screening rates nationwide.

17.
Clin Transl Gastroenterol ; 10(2): e00010, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30829917

RESUMO

OBJECTIVES: The effectiveness of fecal immunochemical test (FIT) screening for colorectal cancer depends on timely colonoscopy follow-up of positive tests, although limited data exist regarding effective system-level strategies for improving follow-up rates. METHODS: Using a mixed-methods design (qualitative and quantitative), we first identified system-level strategies that were implemented for improving timely follow-up after a positive FIT test in a large community-based setting between 2006 and 2016. We then evaluated changes in time to colonoscopy among FIT-positive patients across 3 periods during the study interval, controlling for screening participant age, sex, race/ethnicity, comorbidity, FIT date, and previous screening history. RESULTS: Implemented strategies over the study period included setting a goal of colonoscopy follow-up within 30 days of a positive FIT, tracking FIT-positive patients, early telephone contact to directly schedule follow-up colonoscopies, assigning the responsibility for follow-up tracking and scheduling to gastroenterology departments (vs primary care), and increasing colonoscopy capacity. Among 160,051 patients who had a positive FIT between 2006 and 2016, 126,420 (79%) had a follow-up colonoscopy within 180 days, including 67% in 2006-2008, 79% in 2009-2012, and 83% in 2013-2016 (P < 0.001). Follow-up within 180 days in 2016 varied moderately across service areas, between 72% (95% CI 70-75) and 88% (95% CI 86-91), but there were no obvious differences in the pattern of strategies implemented in higher- vs lower-performing service areas. CONCLUSIONS: The implementation of system-level strategies coincided with substantial improvements in timely colonoscopy follow-up after a positive FIT. Intervention studies are needed to identify the most effective strategies for promoting timely follow-up.

18.
BMJ Open ; 9(1): e025569, 2019 01 25.
Artigo em Inglês | MEDLINE | ID: mdl-30782753

RESUMO

INTRODUCTION: Previous research has shown that multiple factors contribute to healthcare providers perceiving encounters as difficult, and are related to both medical and non-medical demands. AIM: To measure the prevalence and to identify predictors of encounters perceived as difficult by medical residents. DESIGN AND SETTING: Cross-sectional study at the Department of Ambulatory Care and Community Medicine (DACCM), a university outpatient clinic with a long tradition of caring for vulnerable patients. METHOD: We identified difficult doctor-patient encounters using the validated Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10), and characterised patients using the patient's vulnerability grid, a validated questionnaire measuring five domains of vulnerability, both completed by medical residents after each encounter. We used a multiple linear regression model with the outcome variable as the DDPRQ-10 score, controlling for resident characteristics. PARTICIPANTS: We analysed 527 patient encounters performed by all 27 DACCM residents (17 women and 10 men). We asked each medical resident to evaluate 20 consecutive consultations starting on the same date. OUTCOME: One hundred and fifty-seven encounters (29.8%) were perceived as difficult. RESULTS: After adjusting for differences among residents, all five domains of the patient vulnerability grid were independently associated with a difficult encounter: frequent healthcare user; psychological comorbidity; health comorbidity; risky behaviours and a precarious social situation. CONCLUSION: Nearly a third of encounters were perceived as difficult by medical residents in our university outpatient clinic that cares for a high proportion of vulnerable patients. This represents twice the average ratio of difficult encounters in general practice. All five domains of patient vulnerability appear to have partial explanatory power on medical residents' perception of difficult patient encounters.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Assistência Ambulatorial/organização & administração , Atitude do Pessoal de Saúde , Internato e Residência , Relações Médico-Paciente , Adulto , Competência Clínica , Comunicação , Estudos Transversais , Feminino , Humanos , Masculino , Inquéritos e Questionários , Suíça , Universidades
19.
Rev Med Suisse ; 15(634): 129-133, 2019 Jan 17.
Artigo em Francês | MEDLINE | ID: mdl-30657262

RESUMO

Mindfulness meditation and cognitive-behavioral therapy are more cost-effective than conventional management of chronic low back pain. Women with iron deficiency can be treated with oral iron substitution every other day to improve tolerance. Smokers who smoke four or less cigarettes per day have a disproportionately high risk of cardiovascular and cerebrovascular events. All antidepressants are effective in cases of severe depression. Cannabis derivatives have no analgesic effect and do not improve the quality of life of people with neuropathic pain. Cognitive training is effective in cases of mild cognitive impairment. Delegated medical protocols can aid with blood pressure control in hypertensive patients. Nitrofurantoin is the antibiotic of choice for uncomplicated cystitis.


Assuntos
Medicina Interna , Meditação , Atenção Plena , Terapia Cognitivo-Comportamental , Feminino , Humanos , Medicina Interna/tendências , Qualidade de Vida
20.
J Am Board Fam Med ; 31(6): 897-904, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30413545

RESUMO

INTRODUCTION: We aimed to standardize data collection from 3 health systems (HS1, HS2, HS3) participating in the San Francisco Bay Collaborative Research Network, and compare rates and predictors of uncontrolled blood pressure among hypertensive adults to identify opportunities for regional collaboration in quality improvement. METHODS: Retrospective cohort study using deidentified electronic health record data from all primary care patients with at least 1 visit in a 2-year period, using standard data definitions in a common data repository. Primary outcome was uncontrolled blood pressure at the most recent primary care visit. RESULTS: Of 169,793 adults aged 18 to 85 years, 53,133 (31.3%) had a diagnosis of hypertension. Of these, 18,751 (35%) had uncontrolled blood pressure at their last visit, with the proportion varying by system (29%, HS1; 31%, HS2; and 44%, HS3) and by clinical site within each system. In multivariate analyses, differences between health systems persisted, with HS2 and HS3 patients having a 1.15 times (95% CI, 1.11 to 1.19) and 1.46 times (95% CI, 1.42 to 1.50) greater relative risk of uncontrolled blood pressure compared with HS1. Across health systems, hypertensive patients were more likely to have uncontrolled blood pressure if they were uninsured, African Americans, current smokers, obese, or had fewer than 2 primary care visits during the 2-year measurement period. CONCLUSIONS: After controlling for standard individual predictors of hypertension control, significant and substantial differences in hypertension control persisted between health systems, possibly due to local quality improvement programs among other factors. There may be opportunities to share best practices and address common disparities across health systems.


Assuntos
Anti-Hipertensivos/administração & dosagem , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hipertensão/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea/efeitos dos fármacos , Determinação da Pressão Arterial , Feminino , Humanos , Hipertensão/diagnóstico , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Atenção Primária à Saúde/normas , Atenção Primária à Saúde/estatística & dados numéricos , Melhoria de Qualidade , Estudos Retrospectivos , São Francisco , Resultado do Tratamento , Adulto Jovem
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