Multiple procedures and cumulative individual radiation exposure in interventional cardiology: A long-term retrospective study.

INTRODUCTION: Various studies address discrepancies between guideline recommendations for coronary angiographies and clinical practice. While the issue of the appropriateness of recurrent angiographies was studied focusing on the role of the cardiologist, little is known about individual patients' histories and the associated radiation exposures. METHODS: We analyzed all patients with coronary artery disease (CAD) in an academic teaching practice who underwent at least one angiography with or without intervention between 2004 and 2009. All performed angiographies in these patients were analyzed and rated by three physicians for appropriateness levels according to cardiology guidelines. Typical exposure data from the medical literature were used to estimate individual radiation exposure. RESULTS: In the cohort of 147 patients, a total of 441 procedures were analyzed: between 1981 and 2009, three procedures were performed per patient (range 1-19) on average. Appropriateness ratings were 'high/intermediate' in 71%, 'low/no' in 27.6% and data were insufficient for ratings in 1.4%. Procedures with 'low/no' ratings were associated with potentially avoidable exposures of up to 186 mSv for single patients. CONCLUSIONS: Using retrospective data, we exemplify the potential benefit of guideline adherence to decrease patients' radiation exposures. KEY POINTS: • A cohort study of 147 patients showed 27.6% low appropriateness procedures. • Potentially avoidable radiation exposure cumulated up to about 186 mSv for single patients. • Predisposing factors were prior bypass surgery and first treatment in a tertiary centre. • 7.5% of the patients received 58% of the potentially avoidable radiation exposure. • The benefits of guideline adherence in decreasing patient radiation exposure are exemplified.

Stroke knowledge among diabetics: a cross-sectional study on the influence of age, gender, education, and migration status.

BACKGROUND: Stroke campaigns are educating about the need to immediately contact the emergency medical system if symptoms occur. Despite higher stroke rates among patients with diabetics and some migrant populations, there are few data about stroke knowledge in these groups. METHODS: We performed a cross-sectional questionnaire survey among 250 diabetes patients from Germany and Turkey in a primary care and diabetes practice center. The two-page questionnaire asked for stroke knowledge and socio-demographic data. Also, medical and communication data were obtained. Stroke knowledge was defined as good if a participant knew (1) at least two stroke symptoms (good symptom knowledge) and (2) that immediate hospital admission or an emergency call is necessary in case of stroke symptoms (good action knowledge). RESULTS: A total of 231 of 250 patients took part in the survey (participation rate 92.4%) with 134 natives (53.6%), 84 migrants from Turkey (33.6%) and 13 migrants (5.2%) from other countries. Comparing natives and migrants from Turkey good symptom knowledge was documented in 52.8% of the participants, good action knowledge in 67.9%, and good stroke knowledge in nearly forty percent (39.4%) of patients (n = 218). A logistic regression analysis showed better stroke knowledge if patients were younger than 61 years, had good language abilities and were living in an one-generation household (p < 0.05), while gender, years since migration and diabetes control did not play a role. CONCLUSIONS: We documented stroke knowledge deficits among patients with diabetes, both natives and migrants. Additional information strategies for these high risk populations are needed.

Guideline adherence and patient satisfaction in the treatment of inflammatory bowel disorders--an evaluation study.

BACKGROUND: Crohn's disease (CD) and ulcerative colitis (UC) are the most frequent inflammatory bowel disorders (IBD). IBD cause a significant burden to society due to extensive health care utilization from the first clinical symptoms until diagnosis and thereafter due to direct and indirect costs. Besides the socio-economic impact of CD and UC, gastrointestinal and extraintestinal symptoms affect quality of life, but there is remarkably little data about the quality of treatment as assessed by patient satisfaction, quality of life and adherence to guidelines. Thus the aim of this study was to identify variables that influence quality of treatment and quality of life as well as patient satisfaction. METHODS: The Essener Zirkel Study was a cross sectional study of 86 IBD-patients with a confirmed diagnosis of CD or UC. They were recruited at primary, secondary and tertiary care settings. Quality of treatment, quality of life and patient satisfaction were evaluated. Consulting behaviour and number of examinations, duration of disease and variables regarding adherence to guidelines were evaluated, too. RESULTS: 59 (69%) patients had CD and 27 had UC (31%). 19% spent more than four years until the suspected diagnosis of IBD was confirmed and visited more than five physicians. All patients showed a significantly reduced quality of life compared to the 1998 German normative population. In spite of being under medical treatment, nearly half of the patients suffered from strong quality of life restricting symptoms. Over all, 35% described their treatment as moderate or bad. Patients who consulted psychotherapists and non-medical practitioners suffered significantly less from depression. CONCLUSION: Besides structural deficiencies due to the health care policy, we revealed the adherence to guidelines to be a problem area. Our findings support the assumption, that providing better health care and especially maintaining constant patient-physician communication improves patient satisfaction.

Relevance of clerkship characteristics in changing students' interest in family medicine: a questionnaire survey.

OBJECTIVES: Exposure to family medicine (FM) can serve to promote students' interest in this field. This study aimed at identifying clerkship characteristics which decrease or increase students' interest in FM. DESIGN: This cross-sectional questionnaire study analysed students' clerkship evaluations between the years 2004 and 2014. Descriptive statistics were used to compare four predefined groups: (1) high interest in FM before and after the clerkship (Remained high), (2) poor interest before and after the clerkship (Remained low), (3) poor interest before the clerkship which improved (Increased) and (4) high interest before the clerkship which decreased (Decreased). SETTING: Students' evaluations of FM clerkships in the fourth of 6 years of medical school. PARTICIPANTS: All questionnaires with complete answers on students' interest in FM and its change as a result of the clerkship (2382 of 3963; 60.1%). The students' mean age was 26 years (± 3.9), 62.7% (n=1505) were female. OUTCOME MEASURE: The outcome was a change in students' interest in FM after completing the clerkship. RESULTS: Interest in FM after the clerkship was as follows: 40.1% (n=954) Remained high, 5.5% (n=134) Remained low, 42.1% (n=1002) Increased and 12.3% (n=292) Decreased. Students with decreased interest had performed a below-average number of learning activities (4 vs 6 activities). A total of 45.9% (n=134 of 292) of the students with decreased interest reported that the difficulty of the challenge was inadequate for their educational level: 81.3% (n=109) felt underchallenged and 18.7% (n=25) overchallenged. CONCLUSIONS: In more than 50% of cases, the clerkship changed the students' interest in FM. Those with decreased interest were more frequently underchallenged. We observed an increase in FM if at least six learning activities were trained. Our findings stress the importance of well-designed FM clerkships. There is a need for standardised educational strategies which enable teaching physicians to operationalise educational requirements.

Vaccination management and vaccination errors: a representative online-survey among primary care physicians.

BACKGROUND: Effective immunizations require a thorough, multi-step process, yet few studies comprehensively addressed issues around vaccination management. OBJECTIVES: To assess variations in vaccination management and vaccination errors in primary care. METHODS: A cross sectional, web-based questionnaire survey was performed among 1157 primary physicians from North Rhine-Westphalia, Germany: a representative 10% random sample of general practitioners (n = 946) and all teaching physicians from the University Duisburg-Essen (n = 211). Four quality aspects with three items each were included: patient-related quality (patient information, patient consent, strategies to increase immunization rates), vaccine-related quality (practice vaccine spectrum, vaccine pre-selection, vaccination documentation), personnel-related quality (recommendation of vaccinations, vaccine application, personnel qualification) and storage-related quality (storage device, temperature log, vaccine storage control). For each of the four quality aspects, "good quality" was reached if all three criteria per quality aspect were fulfilled. Good vaccination management was defined as fulfilling all twelve items. Additionally, physicians' experiences with errors and nearby-errors in vaccination management were obtained. RESULTS: More than 20% of the physicians participated in the survey. Good vaccination management was reached by 19% of the practices. Patient-related quality was good in 69% of the practices, vaccine-related quality in 73%, personnel-related quality in 59% and storage-related quality in 41% of the practices. No predictors for error reporting and good vaccination management were identified. CONCLUSIONS: We identified good results for vaccine- and patient-related quality but need to improve issues that revolve around vaccine storage.

Hypertension management in primary care: how effective is a telephone recall for patients with low appointment adherence in a practice setting?

BACKGROUND: Studies showed a positive association between appointment adherence and blood pressure control. In randomized-controlled trials blood pressure therapy was improved by recall systems. We analyze the effectiveness of an active telephone recall on blood pressure control for patients with low appointment adherence in regular primary care. METHODS: This retrospective cohort study analyses all hypertensive patients without any hypertension-related disease (primary prevention) of an academic teaching primary care practice using a structured hypertension management. Blood pressure levels at the beginning of the hypertension management and after 1 year were analyzed. Blood pressure control rates (< 140/90 mmHg) and average blood pressure of patients with good appointment adherence and those requiring a phone recall were compared. RESULTS: A total of 410 hypertensive patients were identified. A telephone recall was required in 22 % (n = 92), which was successful in 87 % of patients (n = 80). At the beginning, 66 % of appointment adherent patients had controlled hypertension which increased to 81 % after 1 year. In patients not adhering to appointments the initial blood pressure control rate was 59 % and improved to 74 % after 1 year. Average blood pressure office readings decreased from 141/90 to 136/86 mmHg (p < 0.05) in those adhering to appointments, while it improved from 146/92 to 138/88 mmHg (p < 0.05) in those requiring recall. CONCLUSIONS: Active telephone recall improved blood pressure control of hypertensive patients with low appointment adherence in regular primary care. An active recall can be recommended for other primary care scenarios.

[Screening for diabetic retinopathy in type 2 diabetes: a critical review of an annual routine]. / Screening für diabetische Retinopathie bei Typ-2-Diabetes: Eine kritische Evaluation der jährlichen Routine.

BACKGROUND: The German diabetes guideline published in 2010 recommends an annual retinopathy screening for all type 2 diabetics. Patients' and physicians' questions about the need for this routine procedure prompted our critical review. METHODS: Based on guidelines from six industrial nations, recent scientific studies, and from the type 2 disease management programme of North Rhine-Westphalia we reviewed alternative retinopathy screening strategies and their implications for over- and underuse. RESULTS: A comparison of the English, Australian, US, Swedish, Canadian and German guidelines shows that a fixed screening interval is recommended in four countries, while an individualised, risk profile-adjusted screening interval of up to two to three years is favoured in two countries (Sweden, Canada). Current studies indicate that diabetes patients without retinopathy may safely be screened every two to three years without adverse health outcomes if performed consequently. CONCLUSIONS: An individualised retinopathy screening based on the patient's risk factor profile may be a reasonable alternative to achieve the best possible health outcome and to avoid overuse.