Measuring triadic decision making in older patients with multiple chronic conditions: Observer OPTIONMCC.

OBJECTIVE: To develop a valid and reliable tool to measure triadic decision making between older adults with multiple chronic conditions (MCC), their informal caregivers and geriatricians. METHODS: Video observational study with cross-sectional assessment of interaction during medical consultations between geriatricians (n = 10), patients (n = 108) and informal caregivers (68) by three calibrated raters at the geriatric outpatient department of two Dutch hospitals. The Observer OPTIONMCC instrument was developed, based on the 'Dynamic model of SDM in frail older patients' and the 'Observing Patient Involvement in Decision Making - 5 item scale' (Observer OPTION-5). RESULTS: Factor analysis confirms that it is acceptable to regard the new scale as a single construct. The 7-item single factor solution explained 62.76% of the variability for geriatricians, 61.60% of the variability for patients and 54.32% of the variability for informal caregivers. The inter-rater ICC for the total Observer OPTIONMCC score was .96, .96, and .95 (resp. geriatricians, patients, informal caregivers), with values ranging from .60 to .95 for individual items, showing good levels of agreement. CONCLUSION AND PRACTICE IMPLICATIONS: We conclude that Observer OPTIONMCC is sufficiently valid and reliable to be used for the assessment of triadic SDM in populations of older patients with MCC.

Development of the Multi-Dimensional Analysis of Patient Outcome Predictions (MD.POP) during medical encounters.

OBJECTIVE: Our first objective was to develop the Multi-Dimensional analysis of Patient Outcome Predictions (MD.POP), an interaction analysis system that assesses how HCPs discuss precisely and exclusively patient outcomes during medical encounters. The second objective was to study its interrater reliability. METHOD: The MD.POP was developed by consensus meetings. Forty simulated medical encounters between physicians and an actress portraying a patient were analysed. Interrater reliability analysis was conducted on 20 of those simulated encounters. RESULTS: The MD.POP includes six dimensions: object, framing, value, domain, probability and form of POP. The coding method includes four steps: 1) transcription of the encounter, 2) POP identification, 3) POP dimension coding and 4) POP scoring. Descriptive analyses show that the MD.POP is able to describe verbal expressions addressing the patient's outcomes. Statistical analyses show excellent interrater reliability (Cohen's Kappa ranging from 0.92 to 0.94). CONCLUSION: The MD.POP is a reliable interaction analysis system that assesses how HCPs discuss patient medical, psychological or social outcomes during medical encounters. PRACTICAL IMPLICATION: The MD.POP provides a measure for researchers to study how HCPs communicate with patients about potential outcomes. Results of such studies will allow to provide recommendations to improve HCP's communication about patients' outcomes.

The Patient-Centered Medical Home (PCMH) Framing Typology for Understanding the Structure, Function, and Outcomes of PCMHs.

INTRODUCTION: Patient-centered medical homes (PCHMs) aspire to transform today's challenged primary care services. However, it is unclear which PCMH characteristics produce specific outcomes of interest for care delivery. This study tested a novel typology of PCMH practice transformation, the PCMH framing typology, and evaluated measurable outcomes by each type. METHODS: Using the Patient-Centered Primary Care Collaborative 2012 to 2013 Annual Review, this secondary analysis of the published PCMH literature extracted data from publications of 59 PCMHs. Each of the 59 sites was categorized as 1 of 4 PCMH types: add-on, renovated, hybrid, or integrated. Six outcome measures (cost reductions, decreased emergency department/hospital utilization, improved quality, improved access, increased preventive services, and improved patient satisfaction) were independently coded for each site. Practices were combined based on type, and mean outcomes scores for each measure were displayed on radar graphs for comparison. RESULTS: While each type showed a characteristic pattern of success, only the integrated type improved in all 6 outcomes. No type achieved high success in all measures. DISCUSSION: There seem to be 4 types of PCMH, each of which shows a distinctive outcomes profile. Within the PCMH framing typology, direction is emerging for how best to transform primary care to achieve the greatest success.

El paciente digitalizado / The digitalised patient

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Patient-centered medical homes: observable types derived from national recognition assessment scores.

The patient-centered medical home (PCMH) is a strategy to transform primary care delivery organizations. However, PCMHs take on many forms and can "look different." To better understand the activities of organizations undertaking this strategy, we sought to identify discernible PCMH types using cluster analyses. From a sample of level 3 National Committee for Quality Assurance PCMHs, We extracted 3 types of PCMHs: information-focused, efficiency-focused, and high-scoring. Our findings confirm that the PCMH is not a uniform intervention. Characterizing PCMHs with particular areas of focus has implications for understanding the transformation process, identifying areas for continued practice development, and advancing evaluation of this organizational model.

Grado de implantación de especificaciones de la calidad analítica en España / Level of implementation of analytical quality specifications in Spain

Objetivos: Este trabajo pretende conocer el grado de implantación de las especificaciones de la calidad en los laboratorios clínicos de España y concretamente de las especificaciones mínimas de la calidad analítica consensuadas por el Comité de Expertos Interdisciplinar sobre Especificaciones de la Calidad (CEIEC) en el Laboratorio Clínico, así como la opinión del sector respecto a la necesidad del establecimiento de valores preceptivos de requisitos de la calidad analítica: Material y método: Se diseñó una encuesta que constaba de 22 preguntas, 4 de ellas de tipo descriptivo, 16 retrospectivas y 2 prospectivas. El periodo de recogida de respuestas fue de septiembre a noviembre de 2012. Como requisito de los encuestados solo se consideró que participasen en algún programa de intercomparación de las sociedades científicas españolas representadas en el citado comité. El número de encuestas remitidas fue de 1.738. Resultados: Se recibieron 340 respuestas (19,6% del total). El 59% de los que respondieron tiene implantado un sistema de reconocimiento formal de la calidad. El 83% comprueba si cumplen o no con las especificaciones, el 68% dispone de un compromiso documental de cumplirlas y el 64% ha elaborado el listado con los valores concretos de especificaciones. El 55% conoce la existencia de unas especificaciones mínimas de la calidad consensuadas por el CEIEC. El 49% estaría de acuerdo en que estas especificaciones fueran preceptivas, mientras que el 33% no se define (AU)

Objectives: This work aims to determine the level of implementation of analytical quality specifications in Spanish clinical laboratories and, in particular, the minimum analytical quality specifications obtained by consensus of the Interdisciplinary Expert Committee on Quality Specifications (CEIEC) in the Clinical Laboratory, as well as to determine the opinions of the professionals as regards establishing mandatory analytical quality specifications.. Material and method: A questionnaire was designed including 4 descriptive, 16 retrospective, and 2 prospective questions. The responses were collected during September to November 2012. The requirement for participating was to be involved in an intercomparison program of any of the 4 Spanish scientific societies represented on the abovementioned committee. A total of 1,738 questionnaires were sent. Results: A total of 340 responses (19.6% over the total) were received. The results showed that 59% of respondents have a formally recognized quality system. The attainment of predefined specifications was checked by 83%, with 68% having a commitment for documented quality specifications, and 64% had made a list with specification values. A majority (55%) is aware of the existence of the consensus minimum quality specifications of the CEIEC, and 49% would agree that these specifications should become mandatory, while 33% did not declare a clear position on this subject (AU)

Tratamiento del anciano con diabetes / Treatment of older persons with diabetes

La prevalencia de la diabetes aumenta con la edad. En España, casi un tercio de las personas mayores de 75 años presenta esta patología y el diagnóstico es desconocido en el 10% de los casos. El abordaje en este grupo etario está condicionado por la coexistencia de comorbilidades y síndromes geriátricos, así como por la polifarmacia a la que suelen estar sometidos estos pacientes. Todas las guías de práctica clínica recomiendan que el objetivo de control sea individualizado en función de factores como el tiempo de evolución de la enfermedad, la presencia de complicaciones, el estado funcional, la expectativa de vida y el entorno del paciente, entre otros. El planteamiento terapéutico, en términos generales, no difiere del recomendado en población más joven: multifactorial, considerando cambios de estilo de vida y control de la hiperglucemia y resto de factores de riesgo cardiovascular. La hipoglucemia, más frecuente y grave en este grupo etario, es la principal limitación. Las recomendaciones terapéuticas en los ancianos con diabetes están basadas en la opinión de expertos, ya que los ensayos clínicos suelen excluir a este tipo de pacientes, por lo que se utilizará el juicio clínico para optimizar el tratamiento antidiabético en el que primarán las acciones encaminadas a evitar los síntomas de la enfermedad y mejorar la calidad de vida. Los inhibidores de la DPP-4 pueden ser utilizados por su bajo riesgo de hipoglucemias y seguridad. Se debe realizar una evaluación del estado funcional y cognitivo antes de iniciar cualquier medida terapéutica, valorando la relación riesgo/ beneficio de esta (AU)

The prevalence of diabetes increases with age. In Spain, almost a third of persons older than 75 years have diabetes, and 10% of cases are undiagnosed. The approach in this age group is influenced by the coexistence of comorbidities and geriatric syndromes, as well as by the polypharmacy found in these patients. All the clinical practice guidelines recommend that glycemic control be individually tailored according to such factors as disease duration, the presence of complications, functional status, life expectancy, and the patient's environment, among other elements. In general, the therapeutic approach in older persons does not differ from that recommended in the younger population: it should be multifactorial, considering lifestyle modifications and control of hyperglycemia and the remaining cardiovascular risk factors. The main limitation is hypoglycemia, which is the most common and severe factor in this age group. Therapeutic recommendations in elderly persons with diabetes are based on expert opinion, since these patients are usually excluded from clinical trials. Consequently, clinical judgment is required to optimize the treatment of diabetes, with an emphasis on interventions to prevent symptoms and improve quality of life. DPP-4 inhibitors can be used, due to their low risk of hypoglycemias and safety. Before any treatment is started, its risk/benefit ratio should be evaluated, along with the patient's functional and cognitive status (AU)

A transdisciplinary team approach to perinatal loss.

Pregnancy loss is a unique and life-changing event for the woman and her family. Miscarriages occur in about 15% to 20% of all clinically identified pregnancies in the United States. These pregnancy losses can cause a multitude of problems including physical, emotional, and psychosocial distress. This article discusses how a transdisciplinary team embarked on a 1-year journey to establish a process for providing consistent, high-quality care to women experiencing a pregnancy loss. This team was developed in response to opportunities for improvement at a regional tertiary care center. The team's mission was to develop a uniform standard of compassionate care for these families through a transdisciplinary approach focusing on guidance, support, and information. By sharing the story of our Fetal Demise Task Force, other individuals may be able to identify strengths and weaknesses in their own facilities as they care for women and families experiencing a pregnancy loss.

[Development and validation of a scale aiming at measuring perceived patient-centered care by professionals]. / Développement et validation d'une échelle d'auto-évaluation des pratiques de bientraitance des patients ou des résidents par les professionnels de santé

OBJECTIVE: Patient-centered care is a concept recently implemented in French hospitals. No tools have been developing to measure patient-centeredness perceived by professional. The aim of the project was to develop and to validate a self-measure scale for healthcare providers. METHODS: The project has been conducting from June 2010 to June 2011. A multispecialty working group defined the conceptual framework (brainstorming, formalized consensus method), then built the questionnaire. After the pretest, the tool consisted in 44 items experimented in 35 shifts of 28 organizations. Exploratory and confirmatory psychometric properties were then tested (Principal component analysis, Cronbach' α coefficients, Structural equation modeling). RESULTS: Professional participation rate was 55%. The final solution produced a 16 items questionnaire and 3 dimensions (41,6% of the explained variance): Respect (5 items), Organisation (6 items), Patient and family information (5 items). Cronbach α coefficients were respectively 0,68, 0,83 and 0,68. CONCLUSION: This first patient-centered care scale developed in the French context had good psychometric properties. The questionnaire will be tested another time next year in order to comfort our results and to explore jointly the patient perceptions of patient-centered care.

Language in tuberculosis services: can we change to patient-centred terminology and stop the paradigm of blaming the patients?

The words 'defaulter', 'suspect' and 'control' have been part of the language of tuberculosis (TB) services for many decades, and they continue to be used in international guidelines and in published literature. From a patient perspective, it is our opinion that these terms are at best inappropriate, coercive and disempowering, and at worst they could be perceived as judgmental and criminalising, tending to place the blame of the disease or responsibility for adverse treatment outcomes on one side-that of the patients. In this article, which brings together a wide range of authors and institutions from Africa, Asia, Latin America, Europe and the Pacific, we discuss the use of the words 'defaulter', 'suspect' and 'control' and argue why it is detrimental to continue using them in the context of TB. We propose that 'defaulter' be replaced with 'person lost to follow-up'; that 'TB suspect' be replaced by 'person with presumptive TB' or 'person to be evaluated for TB'; and that the term 'control' be replaced with 'prevention and care' or simply deleted. These terms are non-judgmental and patient-centred. We appeal to the global Stop TB Partnership to lead discussions on this issue and to make concrete steps towards changing the current paradigm.

A new taxonomy for stakeholder engagement in patient-centered outcomes research.

Despite widespread agreement that stakeholder engagement is needed in patient-centered outcomes research (PCOR), no taxonomy exists to guide researchers and policy makers on how to address this need. We followed an iterative process, including several stages of stakeholder review, to address three questions: (1) Who are the stakeholders in PCOR? (2) What roles and responsibilities can stakeholders have in PCOR? (3) How can researchers start engaging stakeholders? We introduce a flexible taxonomy called the 7Ps of Stakeholder Engagement and Six Stages of Research for identifying stakeholders and developing engagement strategies across the full spectrum of research activities. The path toward engagement will not be uniform across every research program, but this taxonomy offers a common starting point and a flexible approach.

Psychometric evaluation of the Swedish version of the Person-Centered Care Assessment Tool (P-CAT).

BACKGROUND: Person-centered care is a multidimensional concept describing good care, especially within aged care and care for people with dementia. Research studies evaluating person-centered care interventions seldom use direct measurement of levels of person-centeredness. Existing scales that measure person-centeredness need further testing. This study evaluated the psychometric properties of the Swedish version of the Person-Centered Care Assessment Tool (P-CAT). METHODS: A cross-sectional sample of 1465 staff from 195 residential care units for older people in Sweden participated in the study. Validity, reliability, and discrimination ability of the scale were evaluated. RESULTS: Confirmatory factor analysis, parallel analysis and exploratory factor analysis supported the construct validity of a two-factor solution. Reliability and homogeneity were satisfactory for the whole P-CAT as demonstrated by a Cronbach's α of 0.75. Test-retest reliability showed temporal stability of the scale, and the discrimination ability of the scale was satisfactory. CONCLUSION: The Swedish version of the P-CAT was found to be valid, reliable, and applicable for further use. Two subscales are recommended for the Swedish version.

Características evolutivas de la incapacidad temporal en un centro de salud / Evolutive characteristics of temporary disability in a health care center

Introducción. El objetivo es valorar la evolución de la incapacidad temporal (IT) en un centro de salud (CS) urbano durante 12 años (1993-2004) mediante un estudio observacional retrospectivo de prevalencia. Pacientes y métodos. Las variables evaluadas son: sexo, duración IT, diagnóstico (según CIE-9), año de la IT y causa de alta obtenidas de los partes de IT registrados en tres consultas de un CS. Resultados: Se registraron 3.924 procesos (58,4% varones). La duración media de la IT es de 46,3 ± 99,4 días para varones y 54,2 ± 103,9 para mujeres (intervalo de confianza de diferencia 1,5-14,4). Para valorar la evolución se han considerado tres periodos: 1993-1996 (1.141 procesos), 19972000 (1.128 procesos), 2001-2004 (1.655 procesos). Los diagnósticos más frecuentes son los osteomusculares (30,6%), infecciosos (23%), trastornos mentales (7,9%) y digestivos (7,2%). Evolutivamente el porcentaje de las causas osteomusculares y digestivas se han mantenido, mientras que las infecciosas han descendido del 27 al 18% y las mentales han aumentado del 6,6 al 10,1%, duplicándose el número de días perdidos por esta causa, pasando de 7.642 días en el primer periodo a 15.686 en el tercero. Las causas osteomusculares son las que más días perdidos originan (76.009 días) seguidas de las mentales (31.147 días). El porcentaje de IT por población activa ha pasado de 19,8% en 1993 a 30,5% en 2004. Conclusiones: Se ha producido un aumento progresivo del porcentaje de IT con respecto a la población activa atendida. En los últimos años las IT por trastornos mentales han aumentado considerablemente, duplicándose el número de días perdidos por esta causa (AU)

Introduction: This study has aimed to assess the evolution of work disablement (WD) for an urban Primary Care Center (PCC) over 12 years (1993-2004) by means of an observational, retrospective study on prevalence. Patients and methods; Variables: Gender, WD duration, diagnosis (according to ICD-9), year of the WD, reason for discharge obtained from WD reports recorded in three doctor’s offices in the PCC mentioned. Results: We recorded 3,924 conditions (58.4% males). Average duration of the WD was 46.3 ± 99.4 days for males and 54.2 ± 103.9 for women (Confidence Interval difference varies from 1.5-14.4). Three periods were used to assess evolution: 1993-1996 (1,141 conditions), 1997-2000 (1,128 conditions), 2001-2004 (1.655 conditions). The most frequent diagnoses were osteomuscular (30.6%), infectious (23%), mental disorders (7.9%) and digestive disorders (7.2%). In regards to evolution, percentages of osteomuscular and digestive causes were maintained whereas the infectious ones decreased from 27% to 18% and the mental ones increased from 6.6% to 10.1%, the number of days lost due to this being double, ranging from 7,642 days in the 1st period to 15,686 in the 3rd one. The most work days lost were due to osteomuscular causes (76,009 days) followed by mental ones (31,147 days). The percentage of WD for the active population has increased considerably, going from 19.8% in 1993 to 30.5% in 2004. Conclusions: There has been a progressive increase in the percentage of WD due to mental disorders in the working population in recent years. WD due to mental disorders has increased considerably in recent years, the number of workdays lost due to it doubling (AU)

Paciente con tumefacción en la articulación esternoclavicular. Síndrome SAPHO / Patient with numbness in the sternoclavicular joint: SAPHO Syndrome

El síndrome SAPHO está constituido por la asociación de alteraciones musculoesqueléticas y alteraciones dermatológicas. Presentamos el caso de un varón de 35 años que cumple criterios de síndrome SAPHO. Aunque el tratamiento de estos pacientes aún no está claro, es importante hacer el diagnóstico del síndrome SAPHO para realizar las investigaciones necesarias e instaurar el tratamiento. El término es un acrónimo de las manifestaciones más frecuentes: sinovitis, acné, pustulosis palmo-plantar, hiperostosis y osteítis (AU)

The SAPHO syndrome describes an association between musculoskeletal disorders and various dermatological conditions. We report the case of a 35-years-old man who fulfilled the criteria for SAPHO. Although the optimal treatment for these patients remains unclear, it is important to make the diagnosis of SAPHO to avoid unnecessary investigations and treatment. SAPHO is an acronym of the combination of synovitis, acne, pustulosis, hyperostosis, and osteitis (AU)

Person-centredness: conceptual and historical perspectives.

PURPOSE: The definition and aims of rehabilitation are both topics of frequent debate. Recently several authors have suggested defining rehabilitation and its goals in terms of 'person-centredness'. However such attempts to define rehabilitation in this way have not occurred without running into their own difficulties and criticisms. Consequently, one may question whether person-centredness is a good candidate to characterize and define rehabilitation. The purpose of this article is to reflect upon the historical background and conceptual underpinnings of this term and their relevance for understanding contemporary person-centred rehabilitation. METHOD: We conducted a conceptual and historical analysis of the notion of person-centredness in relation to rehabilitation. We ask first whether person-centredness has a consistent and fixed definition and meaning? Secondly, where does person-centredness come from, what is its conceptual history and does an historical approach enable us to identify a unique source for person-centredness? RESULTS: In the context of rehabilitation, we have identified four main understandings or interpretations of the term person-centredness, each of which denotes several ideas that can be, in turn, interpreted in quite different ways. Thus the concept of person-centredness in rehabilitation has multiple meanings. The conceptual history indicates that person-centredness has diverse meanings and that it has been used in a variety of contexts somewhat unrelated to disability and rehabilitation. Moreover, there does not seem to be any strict relationship between person-centredness as it is used in the context of rehabilitation and these prior uses and meanings. CONCLUSION: Person-centredness has an ancient pedigree, but its application in the field of rehabilitation raises both practical and theoretical difficulties. It may be that rehabilitation might get a better sense of what it should be and should do by focusing less on the rhetoric of person-centredness and by putting more emphasis on the investigation and operationalization of its key conceptual components.