1,721,197 research outputs found
General practitioners' predictions of their own patients' health literacy: a cross-sectional study in Belgium
No full textOBJECTIVES: To support patients in their disease management, providing information that is adjusted to patients' knowledge and ability to process health information (ie, health literacy) is crucial. To ensure effective health communication, general practitioners (GPs) should be able to identify people with limited health literacy. To this end, (dis)agreement between patients' health literacy and GPs' estimations thereof was examined. Also, characteristics impacting health literacy (dis)agreement were studied. DESIGN: Cross-sectional survey of general practice patients and GPs undertaken in 2016-17. SETTING: Forty-one general practices in two Dutch-speaking provinces in Belgium. PARTICIPANTS: Patients (18 years of age and older) visiting general practices. Patients were excluded when having severe impairments (physical, mental, sensory). MAIN OUTCOME MEASURES: Patients' health literacy was assessed with 16-item European Health Literacy Survey Questionnaire. GPs indicated estimations on patients' health literacy using a simple scale (inadequate; problematic; adequate). (Dis)agreement between patients' health literacy and GPs' estimations thereof (GPs' estimations being equal to/higher/lower than patients' health literacy) was measured using Kappa statistics. The impact of patient and GP characteristics, including duration of GP-patient relationships, on this (dis)agreement was examined using generalised linear logit model. RESULTS: Health literacy of patients (n=1375) was inadequate (n=201; 14.6%), problematic (n=299; 21.7%), adequate (n=875; 63.6%). GPs overestimated the proportion patients with adequate health literacy: adequate (n=1241; 90.3%), problematic (n=130; 9.5%) and inadequate (n=4; 0.3%). Overall, GPs' correct; over-/underestimations of health literacy occurred for, respectively, 60.9%; 34.2%; 4.9% patients, resulting in a slight agreement (κ=0.033). The likelihood for GPs to over-/underestimate patients' health literacy increases with decreasing educational level of patients; and decreasing number of years patients have been consulting with their GP. CONCLUSIONS: Intuitively assessing health literacy is difficult. Patients' education, the duration of GP-patient relationships and GPs' gender impact GPs' perceptions of patients' health literacy.status: Publishe
Clinical audit of quality of care among patients with viral hepatitis in primary care in a low endemic region
No full textBACKGROUND: The current hepatitis B (HBV) and hepatitis C virus (HCV) screening practices may fail to detect many infected patients who could benefit from new therapeutic agents to limit progression to cirrhosis and hepatocellular carcinoma. OBJECTIVES: This study assessed the test positivity rate and cascade of care of viral hepatitis patients in primary care in a low endemic region as well as the testing policy of abnormal alanine aminotransferase (ALT) level. METHODS: This is a retrospective clinical audit among primary health care practices in Flanders, Belgium, assessing patients with an active medical file between 2019 and 2021. RESULTS: A total of 84/89 (94.4%) primary health care practices participated representing 621,573 patients of which 1069 patients (0.17%) were registered as having viral hepatitis, not further specified. Detailed information was available from 38 practices representing 243,723/621,573 (39.2%) patients of which 169 (0.07%) were HBsAg positive and 99 (0.04%) anti-HCV positive. A total of 96/134(71.6%) chronic HBV-infected and 31/77(40.3%) chronic HCV-infected patients were referred to a hepatologist. A total of 30,573/621,573(4.9%) patients had an abnormal ALT level, and by at random selection, more detailed information was obtained on 211 patients. Information on high-risk groups was missing in up to 60%. In patients with abnormal ALT level, HBsAg and anti-HCV testing were conducted in 37/211(17.5%) and 25/211(11.8%), respectively. CONCLUSION: In a low endemic region, the testing rate and cascade of care of HBV and HCV-infected patients can be improved in primary care, especially in high-risk groups and patients with abnormal ALT levels.</p
General practitioners' perceptions about their role in current and future heart failure care: an exploratory qualitative study
No full textBACKGROUND: A comprehensive disease management programme (DMP) with a central role for general practitioners (GPs) is needed to improve heart failure (HF) care. However, previous research has shown that GPs have mixed experiences with multidisciplinary HF care. Therefore, in this study, we explore the perceptions that GPs have regarding their role in current and future HF care, prior to the design of an HF disease management programme. METHODS: This was a qualitative semi-structured interview study with Belgian GPs until data saturation was reached. The QUAGOL method was used for data analysis. RESULTS: In general, GPs wanted to assume a central role in HF care. Current interdisciplinary collaboration with cardiologists was perceived as smooth, partly because of the ease of access. In contrast, due to less well-established communication and the variable knowledge of nurses regarding HF care, collaboration with home care nurses was perceived as suboptimal. With regard to the future organization of HF care, all GPs confirmed the need for a structured chronic care approach and envisioned this as a multidisciplinary care pathway: flexible, patient-centred, without additional administration and with appropriate delegation of some critical tasks, including education and monitoring. GPs considered all-round general practice nurses as the preferred partner to delegate tasks to in HF care and reported limited experience in collaborating with specialist HF nurses. CONCLUSION: GPs expressed the need for a protocol-driven care pathway in chronic HF care. However, in contrast to the existing care trajectories, this pathway should be flexible, without additional administrative burdens and with a central role for GPs.status: Publishe
Mixed-methods evaluation of a multifaceted heart failure intervention in general practice: the OSCAR-HF pilot study
No full textAIMS: Heart failure (HF) is an important health problem for which multidisciplinary care is recommended, yet few studies involve primary care practitioners in the multidisciplinary management of HF. We set up a multifaceted prospective observational trial, OSCAR-HF, piloting audit and feedback, natriuretic peptide testing at the point of care, and the assistance of a specialist HF nurse in primary care. The aim was to optimize HF care in general practice. METHODS AND RESULTS: This is an analysis at 6 month follow-up of the study interventions of the OSCAR-HF pilot study, a nonrandomized, noncontrolled prospective observational trial conducted in eight Belgian general practices [51 general practitioners (GPs)]. Patients who were assessed by their GP to have HF constituted the OSCAR-HF study population. We used descriptive statistics and mixed-effects modelling for the quantitative analysis and thematic analysis of the focus group interviews. There was a 10.2% increase in the registered HF population after 6 months of follow-up (n = 593) compared with baseline (n = 538) and a 27% increase in objectified HF diagnoses (baseline n = 359 to 456 at T6 M). Natriuretic peptide testing (with or without referral) accounted for 54% (n = 60/111) of the newly registered HF diagnoses. There was no difference in the proportion of patients with HF with reduced ejection fraction who received their target dosage of renin-angiotensin-aldosterone system inhibitors or beta-blockers at 6 months compared with baseline (P = 0.9). Patients who received an HF nurse intervention (n = 53) had significantly worse quality of life at baseline [difference in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score 9.2 points; 95% confidence interval (CI) 4.0, 14] and had a significantly greater improvement in quality-of-life scores at the 6 month follow-up [change in MLHFQ score -9.8 points; 95% CI -15, -4.5] than patients without an HF nurse intervention. GPs found audit and feedback valuable but time intensive. Natriuretic peptides were useful, but the point-of-care test was impractical, and the assistance of an HF nurse was a useful addition to routine HF care. CONCLUSIONS: The use of audit and feedback combined with natriuretic peptide testing was a successful strategy to increase the number of registered and objectified HF diagnoses at 6 months. GPs and HF nurses selected patients with worse quality-of-life scores at baseline for the HF nurse intervention, which led to a significantly greater improvement in quality-of-life scores at the 6 month follow-up compared with patients without an HF nurse intervention. The interventions were deemed feasible and useful by the participating GPs with some specific remarks that can be used for optimization. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02905786), registered on 14 September 2016 at https://clinicaltrials.gov/.sponsorship: Miek Smeets was funded by the Department of Cardiovascular Diseases, UZ Leuven (KUL), and by the Department of Public Health and Primary Care (KUL). Willem Raat was funded by the Department of Public Health and Primary Care (KUL). Jan Vercammen (HF nurse) was funded by the Department of Cardiovascular Diseases, ZOL Genk. Support for study personnel in the Leuven region was provided by an unrestricted research grant financed by Novartis (S54755). Roche Diagnostics provided the NT-proBNP POC devices. Novartis and Roche had a role in the design of this study, and they did not have any role during execution, analyses, interpretation of the data, or decision to submit the results of this study. Miek Smeets was rewarded for her work by the Viviane Conraads Price in 2017. (Department of Cardiovascular Diseases, UZ Leuven, Department of Public Health and Primary Care, Department of Cardiovascular Diseases, ZOL Genk, Novartis, S54755)status: Publishe
Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review
No full textBackground Our aim was to identify which clinical features have value in confi rming or excluding the possibility of
serious infection in children presenting to ambulatory care settings in developed countries.
Methods In this systematic review, we searched electronic databases (Medline, Embase, DARE, CINAHL), reference
lists of relevant studies, and contacted experts to identify articles assessing clinical features of serious infection in
children. 1939 potentially relevant studies were identifi ed. Studies were selected on the basis of six criteria: design
(studies of diagnostic accuracy or prediction rules), participants (otherwise healthy children aged 1 month to 18 years),
setting (ambulatory care), outcome (serious infection), features assessed (assessable in ambulatory care setting), and
suffi cient data reported. Quality assessment was based on the Quality Assessment of Diagnostic Accuracy Studies
criteria. We calculated likelihood ratios for the presence (positive likelihood ratio) or absence (negative likelihood
ratio) of each clinical feature and pre-test and post-test probabilities of the outcome. Clinical features with a positive
likelihood ratio of more than 5·0 were deemed red fl ags (ie, warning signs for serious infection); features with a
negative likelihood ratio of less than 0·2 were deemed rule-out signs.
Findings 30 studies were included in the analysis. Cyanosis (positive likelihood ratio range 2·66–52·20), rapid
breathing (1·26–9·78), poor peripheral perfusion (2·39–38·80), and petechial rash (6·18–83·70) were identifi ed as
red fl ags in several studies. Parental concern (positive likelihood ratio 14·40, 95% CI 9·30–22·10) and clinician
instinct (positive likelihood ratio 23·50, 95 % CI 16·80–32·70) were identifi ed as strong red fl ags in one primary care
study. Temperature of 40°C or more has value as a red fl ag in settings with a low prevalence of serious infection. No
single clinical feature has rule-out value but some combinations can be used to exclude the possibility of serious
infection—for example, pneumonia is very unlikely (negative likelihood ratio 0·07, 95% CI 0·01–0·46) if the child is
not short of breath and there is no parental concern. The Yale Observation Scale had little value in confi rming (positive
likelihood ratio range 1·10–6·70) or excluding (negative likelihood ratio range 0·16–0·97) the possibility of serious
infection.
Interpretation The red fl ags for serious infection that we identifi ed should be used routinely, but serious illness will
still be missed without eff ective use of precautionary measures. We now need to identify the level of risk at which clinical action should be taken.sponsorship: This study was funded by the Health Technology Assessment Project 07/37/05 (Systematic review and validation of clinical prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care) and the National Institute for Health Research National School for Primary Care Research. We would like to thank Paul Glasziou (Centre for Evidence Based Medicine, Oxford, UK) for advising us on the tables and figures. The Fonds Wetenschappelijk Onderzoek Vlaanderen (Research Foundation-Flanders) initially funded the study by Van den Bruel and colleagues' and granted extension to pay for some of the work presented in this report. (Health Technology Assessment|07/37/05, National Institute for Health Research National School for Primary Care Research, Fonds Wetenschappelijk Onderzoek Vlaanderen)status: Publishe
Proeven van (on)zekerheid: diagnostisch onderzoek over 'pijn op de borst' in de huisartspraktijk
Full text linkOver the last 20 years, a substantial change in the epidemiology of acute myocardial syndrome (ACS) has occurred. Non-ST-segment elevation myocardial infarction (NSTEMI) now constitutes the majority of AMIs and the 30-days fatality rate of hospitalized AMI patients has improved markedly with a decrease of 56%.(1) One of the reasons for the decrease is the decline in AMI severity, probably due to the contribution of prevention therapy and the use of aspirin and beta-blockers before admission.(2) Another reason is the improvement of the management of patients with ACS, including pharmacological treatment (beta-blockers, statins, angiotensin-converting enzymes) with or without percutaneous coronary intervention (PCI). In STEMI patients in hospital, mortality decreased from 8.4% to 4.6% and in NSTEMI patients from 2.9% to 2.2 % (not significant) between 1999 and 2005.(3)To maximize patient outcome it is important that GPs refer ACS patients urgently to start treatment as soon as possible.(4,5,6)In contrast to the 30-days mortality, the one-year mortality did not change, although the mortality related to cardiovascular diseases decreased from 62% to 50% in the period 87-91 versus 2002-2006.(1)In the study of Chan et al., where every patient underwent cardiac catheterization, one-year mortality was 9.5% for STEMI patients and 14.3% for NSTEMI.(2) The higher mortality rate for NSTEMI than STEMI was also found in other studies.(1,3,7) Reasons for the higher mortality were co-morbidity and probably insufficient prescription of guideline-recommended medications on discharge.(7) It may be an important role for the GP during follow-up of those patients to make sure that they are treated in anappropriate manner.Acute myocardial infarction and acute coronary syndrome are studied very intensively; a search in Pubmed of Myocardial Ischemia today (03.04.2010) produces 311,505 references, and in combination with Diagnosis there are still 190,096 references. But of those 190,096 references, only 1,369 remain in combination with Primary Health Care or Physicians, Family. Less than 0.7 % of all AMI or ACS diagnostic studies were done in primary health care or in a general practice setting. In order to support the continuous improvement of general practice, we tried to increase the knowledge about GPs treatment decisionsin relation to patients presenting with chest pain. We investigated this domain with a variety of designs: a diagnostic systematic review, a qualitative study to detect some of the criteria a GP uses when dealing with chest pain patients, an observational study to confirm some of the results of this qualitative study, and finally a simulation model to study the influence of changing the treatment threshold on the number of treated patients. In this chapter, we will discuss the main results of these studies, as well as their limitations and the proposal of a research agenda for issues that were not covered. 1. Dealing with chest pain within general practiceAccuracy of typical signs and symptomsWe conducted a diagnostic meta-analysis to determinate the accuracy of ten important signs and symptoms in referred and non-referred patients. Based on our inclusion criteria, we selected 28 studies. We were as strict as possible with respect to the completeness and rigour of the follow-up in the selected studies. 16 out of the 28 selected studies included non-selected patients. In this group absence ofchest wall tenderness on palpation had a pooled sensitivity of 92% (95% CI: 86 to 96) for acute myocardial infarction and 94% (95% CI: 91 to 96) for acute coronary syndrome. Oppressive pain followed with a pooled sensitivity of 60% (95% CI: 55 to 66) for acute myocardial infarction. Sweating had the highest pooled positive LR, namely 2.92 (95% CI: 1.97 to 4.23) for acute myocardial infarction. The other pooled positive LRs fluctuated between 1.05 and 1.49. Negative LRs varied between 0.98 and 0.23. Absence of chest wall tenderness on palpation had a negative LR of 0.23 (95% CI: 0.18 to 0.29).Based on this meta-analysis, we were not able to define an important role for most individual signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low prevalence settings. After the publication of this meta-analysis one additional study was published and we are aware of two more which have not yet been published.(8) All three studies largely confirm our results. Only two studies were performed in a general practice setting, so we decided to look for primary care studies, defined as settings in which patients were seen who were not referred by other medical practitioners. Most of the pooled results were heterogeneous, due to different settings, inclusion criteria and reference standards. The non-homogeneous pooled results in particular must be interpreted very carefully. Some studies suggested a difference in the diagnostic accuracy of signs and symptoms according to age(9,10) or gender(11), but the number of available studies was insufficient to perform subgroup analysis.Although the combination of signs and symptoms, their context, the severity and the progression from the start influenced the interpretation, it was impossible to study this because there were (almost) no included studies which studied the diagnostic accuracy of combinations of signs and symptoms. Only three of the selected studies combined different signs and symptoms, i.e. Short(12) (previous or not-previous history of acute coronary syndrome and studied signs and symptoms), Lee(13) (sharp or stabbing pain and pain pleuretic, positional or reproduced by palpation and no prior acute coronary syndrome) and Hartgarten(14) (radiating pain and sweating; difficult breathing and nausea/vomiting). In Lees study, the combination of three variables sharp or stabbing pain, no history of angina or myocardial infarction, and pain that was reproduced by chest-wall palpation or that had a pleuretic or positional component identified the lowest-risk group. Of 48 such cases, not one patient had a diagnosis of myocardial infarction, unstable angina, or stable angina. Other variables, including age, sex and risk factors for coronary artery disease, did not contribute further to the identification of a low-risk group. Research agenda Studies on chest pain with or without additional signs and symptoms in a primary care setting are necessary to improve diagnosis in a setting with only 5% of all chest pain patients having a serious cardiac disorder.(15) Individual patient data (IPD) of different studies can be combined to obtain better results. Such a study is currently being prepared within an international collaboration.Referring or not referring patients In qualitative studies, the goal is not to recruit a representative sample of participants to quantify opinions, but rather to elicit all possible opinions and views on a specific subject. In a semi-structured interview, 21 GPs were asked to describe why they did or did not refer a patient presenting with chest pain. Interviews were taped, transcribed and qualitatively analysed. Histories of 21 patients were studied. Six were not referred, seven were referred to a cardiologist and eight to the emergency department. In our data, saturation was reached, which probably suggests that the most important criteria were identified. All the interviews were conducted with highly motivated GPs and they responded honestly and voluntarily to the interviewer. The latter was illustrated by the ten GPs explaining cases where they possibly made an error. The interviews were taken within a couple of days after the GP had seen the patient with chest pain, to prevent the GPs reinterpreting their diagnostic reasoning in the light of information from a cardiologist or based on the evolution of the patients condition. This study suggests that the background knowledge on the patient, the patients current clinical presentation and the GPs personal opinions are used by GPs when deciding on whether or not to refer a patient with chest pain to secondary care. It is striking that background knowledge on the patient coronary risk factors, differences in behaviour, playing down the seriousness was considered to be an important factor in the decision-making process. For those factors, knowing the patient is essential. The current clinical presentation with the results of the physical examination in particular is used to rule in diseases other than acute coronary syndrome which need no referral. An ECG was used to confirm the presence of an acute coronary syndrome and refer the patient. A normal ECG was a reason for not referring, but only in combination with long duration of the pain and in absence of risk factors. Additionally, the GPs gut feeling is sometimes more important than the presence of individual signs and symptoms. The GPs personal ideas the patients age, perception of a negative attitude from the medical rescue team, recent patient contact with a cardiologist, past errors were additional factors in the decision-making process. Sometimes, uncertainty about the diagnosis caused an unnecessary referral. Referring older people had a higher threshold than referring younger people. The recruitment of GPs who were willing to participate in the interviews was a difficult process. The prospect of being judged and facing possible criticism may have been a reason for non-collaboration. Loss of time without financial compensation could be another reason. More reminders may have been helpful. Although e-mail is an easy way to recruit GPs, the response proved to be limited. Compared to the general population of GPs in Flanders, the participating GPs were similar in age and practice organization single-handed or group practice but not in gender: female GPs are underrepresented in our sample. Our data did not reveal any difference in reasoning between the three females or the three trainees, and the male group of experienced participants. Of course, gender bias is always possible. In addition, we have to take into consideration the difference between reported behaviour and actual performance.(16,17)Research agendaThe new reasons for referral mentioned in our study, namely differences in patient behaviour, gut feeling, the perception of a negative attitude from the medical rescue team, should now be further evaluated for their effect in a subsequent quantitative study, in a synthesis of qualitative studies or both. 2. Patients with chest pain within general practice: an observational studyCertainty of initial diagnosis and referral rate1996 patients were included (male 52%). A majority of patients consulting with chest pain are not referred by their GP. However, 40% of the patients were suspected of having a serious disease and had to be referred.Men were referred more often (OR=1.44; 95% CI: 1.13 to 1.82). Age showed no relationship to referral (OR=1.06; 95% CI: 0.83 to 1.35) but predicts urgent referral (OR=1.46; 95% CI: 1.02 to 2.08). Not maleness or age alone, but probably the increased risk of serious heart disease in men versus women and in older versus younger age groups are the reasons for this higher urgently referral rate. Also, the higher number of initial diagnoses of somatoform disorder, which seldom results in referral, may be a reason for the low number of urgent referrals in women.Patients suspected of having serious heart disease are referred in 85% of cases. Odds ratios for referral were high with 11.58 (95% CI: 5.72 to 23.44) when the GP was certain of his diagnosis and 2.96 (95% CI: 1.59 to 5.51) if not, versus patients not suspected of having serious heart disease. If the GP was uncertain, in all disease categories 54% (95% CI: 48 to 59) of the patients were referred non-urgently. The high rate of referrals in case of uncertainty in all initial diagnostic categories could beexplained by the fear of missing a serious diagnosis. Fifty-seven patients in whom the GP was certain of his initial diagnosis of serious heart disease were not referred. We found this strange as we would have expected almost all of these patients to be referred for further work-up. To explore this phenomenon, we conducted a phone survey of the GPs including 23 randomly selected patients. It revealed 12 patients with known heart disease and numerous past referrals for which the situation did not really represent an aggravation. For six patients, the hypothesis of serious heart disease could be ruled out after careful physical examination and history taking. One patient refused referral and no information was retained about four patients. Apart from the latter four, none of these situations really required a referral. Such findings are specific for general practice and important when discussing referral rates.Research agendaAn observational study on the reasons for the certainty or uncertainty of the working diagnosis would be very interesting. Certainty of a working diagnosis and certainly uncertainty are influenced by gut feeling. A follow-up study to find out the final diagnosis would give us more information on the value of gut feeling. Mortality and referral rate1558 patients were included. We standardised our group according to age and gender of the Belgian population of 1999. Three-day standardized mortality ratio was 151.0 (95% CI: 82.3 to 250.3) for urgently referred patients, 45.5 (95% CI: 12.4 to116.0) for non-urgently and 13.6 (95% CI: 1.7 to 49.4) for non-referred patients. The one-month standardized ratios were respectively 27.6 (95% CI: 18.0 to 40.4), 6.7 (95% CI: 2.5 to 14.6) and 4.7 (95%CI: 1.9 to 9.7). The standardized ratios of two to twelve months were normal for the urgent referral group (1.3; 95% CI: 0.7 to 2.2) and for the non-urgent referral group (1.0; 95% CI: 0.5 to 1.9) and even less in the non-referred group (0.4; 95% CI: 0.2 to 0.9).Mortality in the first three days and first month after consulting for chest pain is very high. There is a marked trend in mortality according to the referral type urgently referred, non-urgently referred and not referred suggesting effective risk stratification by the general practitioner. After one month, mortality normalises for all groups,suggesting that the surviving patients are well-treated and the condition causing the chest pain no longer influences survival compared to the general population. Because of the relatively small number of events, the 95% CI, especially for the mortality within three days, is very wide. So these results should be interpreted with caution. In the six cases where a patient was not referred urgently and died within three days, the patients refused urgent referral, presented with no or unclear signs and symptoms or experienced a quickly changing medical situation. It is possible that GPs are reluctant to urgently refer patients with low disease probability. We received follow-up information on 86% of the patients. However, information could not be retrieved from 7.8% of patients because the GPs could not identify their patients, based on the identification code they supplied to the research group. Most missing patients were non-referred patients, who were the youngest and healthiest, probably rarely consulting the GP. This is also the reason why the mortality ratios may have been slightly overestimated, because more information about the non-referred patients (with the lowest mortality) is missing than from the other groups. Assuming that there were no deceased patients in the missing group, the one-month mortality rate would change from 0.8 to 0.6% for the non-referred patients group, from 1.4 to 1.2% for the non-urgent referred group and from 10.7 to 8.6% for the urgently referred group. On the other hand, assuming that all patients from the missing data group died, the one-month mortality rate would change to 25.9%, 17.9% and 27.2% respectively. We do not have a final diagnosis for the non-referred patients, in whom acute coronary may be a minor event and may even go undetected.23 But, since this study was designed to evaluate mortality, it does not affect our conclusions. Research agendaOur present study has yielded some hypotheses that could be further investigated in future studies. The marked trend in mortality between urgently referred, non-urgently referred and non-referred patients suggests that GPs adequately stratify the risk for immediate mortality. However, it is not always clear which threshold they use to refer a patient with chest pain, and what influences this threshold.Moreover, the question as to their preference for urgent or non-urgent referral is as yet unresolved. Secondly, although the mortality in non-urgently referred and non-referred patients was lower than that in the urgently referred category, these patients do experience an increased risk for immediate mortality compared to the general population. A new study with registration of all final diagnoses would allow further research on risk factors for immediate mortality and could be incorporated in referral decisions in the future.Transport and referral rate 1996 patients were included. For non-urgently referred patients, 92.7% (95% CI: 89.1to 95.2) were transported by family and neighbours, 4.8% (95% CI: 2.8 to 7.9) by ambulance and 2.5% (95% CI: 1.2 to 5.1) by GPs themselves. For urgently referred patients, ambulances transported 56.9% (95% CI:51.1 to 62.7), family and neighbours 36.9% (95% CI: 31.4 to 42.7) and the GP 6.1% (95% CI: 3.7 to 9.5). There was a significant difference in mortality rate according to the type of transport: of the 73 patients who were transported by ERT, 8(11.0%) died within a period of three days; of the 100 transported by ambulance, 6 (6.0%) died; of the 26 transported by the GP, 1 (3.8%), died; and of the 401 transported by neighbours or family, 4 (1%) died. Almost half of the urgently referred patients with chest pain are transported in unsafe conditions. A possible bias is the large number of missings in the non-urgently referred patients. There are several explanations for this: these patients did not go to the specialist, they did not return to the GP, or the GP neglected this part of the registration. Including the 18 patients with ACS without known transport type could change the suboptimal transport from 53% to 51% (if all 18 were transported by ambulance) or to 61.1% (if no one was transported by ambulance). Research agenda In our qualitative study we found that the perception of a negative attitude from the medical rescue team was a factor for not urgent referring. More investigation of this may be very interesting. Survey among GPs after they have called an ambulance is a possibility. Interviews with physicians of the medical rescue teams may be useful too. 3. Treatment thresholdsThe distribution of disease probabilities after multiple testing and the effect of modifying (i.e. lowering) the treatment threshold on the proportions of treated patientsLowering the threshold from 95% to 50% and 5% in simulations with a prevalence of 50%, 10% and 1% after tests with high accuracy has nearly no influence on the number of patients treated because the diseased and non-diseased patients groups are nearly perfectly separated. In real situations, using tests with lower accuracy, lowering the threshold will increase the number of treated patients substantially. More diseased patients are treated than non-diseased down to a threshold of 5% and prevalence of 10%. Under these values it is the opposite, but nearly all diseased patients are treated. Physicians fear applying low thresholds, they correctly estimate based on utility theory, because they intuitively see post test probability distributions as Gaussian (Van den Ende J, Bruyninckx R. By lowering the threshold, we'll treat them all. International workshop on clinical reasoning. King's College, London. 2010). This study might help convincing clinicians that for a wide range of prevalences and test accuracies, bringing the threshold down is entirely justified. Three studies on tuberculosis in developing countries proved that by lowering the treatment threshold the number of treated patients did not increase linearly and that many more diseased patients were treated.(18,19,20)A simulation is not the real life situation. First, we supposed all tests to perform independently of each other. In real life, some tests will interact with each other to a certain extent. Second, for convenience, we did not apply different accuracies to consecutive tests. Otherwise, we would have a multitude of final post-test probabilities, with insufficient numbers per category for representation as a distribution. Third, we did order all ten tests for all patients, which is not realistic. If the disease probability plummets under a certain threshold, no more tests are ordered, and vice versa for a high post testprobability.(21)It was not our intention to determine the threshold according to the principles of Pauker and Kassirer, based on the result of the benefit and risk/cost for the diseased patients and the disutility for the non-diseased patients, but to study the influence of different hypothetical thresholds on the number of treated and untreated patients.(21,22)Research agendaThe effect of using different treatment thresholds on the number of diseased and non-diseased patients treated should be applied to other existing datasets with other diseases than tuberculosis, different prevalences and different settings, including primary, secondary and tertiary care. Final conclusionIt was not possible to define an important role for individual signs and symptoms in the di
SERIOUS INFECTION IN ACUTELY ILL CHILDREN IN PRIMARY CARE: Validating clinical prediction rules and added value of vital signs and point-of-care tests
No full textBackground: Acute infection is the most common presentation of children to ambulatory care. In contrast, serious infections are rare and often present at an early stage. To avoid complications or death, early recognition and adequate referral are essential. In a recent large study children were included prospectively to construct a symptom-based decision tree with a sensitivity and negative predictive value of nearly 100%. To reduce the number of false positives, point-of-care (POC) tests might be useful, providing an immediate result at the bedside. The most probable candidate is C-reactive protein. Every clinician should reassure anxious parents of children with self-limiting illnesses. The improvement of diagnostic algorithms, the addition of technological devices and the sensible use of safety netting procedures could improve prognosis of seriously ill children.
Methods: First, we externally validated clinical prediction rules, identified by a systematic review, in 7 urgent-access datasets, as well as comparing these results to recent findings in other studies. After zooming in on the diagnostic value of the clinical prediction rules based on vital signs with potential to differentiate serious infections from the majority of self-limiting illnesses in an inpatient paediatric setting in the UK, we focused our analyses on the temporal & geographic validation of the decision tree based on signs and symptoms in a new but similar population in Flanders. We examined the analytical accuracy and user-friendliness of a POC test after careful selection of a device that meets all our requirements. Finally we explored the added value of the selected POC CRP test in a prospective diagnostic accuracy study in three different ambulatory care settings: general practice, outpatient paediatric clinic, and the emergency department.
Results: In low to intermediate prevalence settings the 4-step decisionnbsp;and evidence-based guidelines had high sensitivity, providing promising rule-out value for serious infections in 7 datasets. The paediatrician’s overall illness assessment was the most useful feature to rule in sepsis or meningitis in a study of hospitalized children. Temporal validation of the 4-step decision tree indicated that this practical tool for diagnostic triage of acutely ill children in primary care is valid and ready to be implemented in routine care, if appropriate safety netting or additional testing is applied. The selected POC CRP test was accurate in children and should be considered reliable and user-friendly. Adding point-of-care CRP test results to the 4-step decision tree helped identifying serious infections in the GP setting and can potentially reduce the number of investigations and admissions in children with non-serious infections. I propose a new decision tree to be used in specialist settings as a triage instrument to safely rule out serious infections.
Discussion: The incidence of serious infections has declined over the past few years, amongst other reasons, due to vaccination strategies and improvements in neonatal care. Before a clinical prediction rule can be implemented in routine care, it has to go through several stages of development and testing. A single test will never reach perfect sensitivity and specificity in real life. To tackle the ever-present clinical uncertainty, physicians often put a safety net in place, informing parents when to re-contact and which alarm signs are relevant to monitor. I put an emphasis on these issues and offer a perspective for future developments in the field of point-of-care testing in serious infections in paediatric primary care.status: Publishe
Spirituality at the end of life: art or science?
No full textBackground: The World Health Organization defines palliativecare as encompassing the control of pain and other symptoms and psychological, social, and spiritual care. Most patients experiencing life-threatening illness want the medical team to address their spirituality. Nevertheless, the provision of spiritual care in everyday practice remains difficult. Health care providers face many obstacles, such as discomfortwith the subject, inability to find the right words or a lack of specific training. line-height:115%">Aim: Calibri" lang="EN-GB">The overall aim of this thesis was to study spirituality in palliative home care from different perspectives. We aimed to answer the following questions: how do general practitioners (GPs) perceive their role in spiritual care (RQ1)? What are the key elements of spiritual care in palliative home care (RQ 2)? What are the key outcome measures for spiritual care in palliative home care (RQ 3)? What are GPs views on the use of the FICA tool for spiritual history taking (RQ 4)? How do GPs, nurses, and their patients experience thears moriendi model (AMM) as a tool for spiritual history taking (RQ 5)?What is the effect of structured spiritual history taking on the spiritual well-being of palliative patients (RQ 6)? What challenges need to beovercome to recruit patients with an incurable, life-threatening illness for research in home care (RQ 7)? line-height:115%">Methods: Firstly we carried out a qualitative synthesis of the evidence (RQ 1). We then organised an invitational conference involving experts in palliative and spiritual care to reach a consensus on key elements and outcome measures for spiritual care in palliative home care (RQ 2 & 3). For this we used the nominal group technique, followed by atwo-stage web-based Delphi process. In a third stage we conducted semi-structured interviews with GPs to investigate their views about the FICAtool (RQ 4). We piloted the AMM and subsequently interviewed health care providers and palliative patients to investigate their experiences with the model (RQ 5). Afterwards we carried out a cluster randomised controlled trial (RCT) to investigate the effect of structured spiritual history taking on the spiritual well-being of palliative patients (RQ 6). The health care providers assigned to the intervention arm of the RCT completed a survey immediately after taking the history and participated in a semi-structured interview a few weeks later to investigate their experience with the AMM (RQ 5). Finally, we described the challenges we met in the recruitment of health care providers and palliative patients for the RCT (RQ 7).line-height:115%">Results: Many GPssee it as their role to identify and assess patients spiritual needs despite perceived barriers such as lack of time and lack of specific training (RQ 1). The experts attending the invitational conference reached consensus about 14 key elements and three key outcome measures for spiritual care (RQ 2 & 3). The FICA tool seems to be a usable tool for spiritual history taking, provided that certain substantive and linguisticadjustments are made (RQ 4). Guided by the AMM, health care providers can gather information about the context, life story, and meaningful connections of their patients, enabling them to organise person-centred palliative care with respect for the spiritual dimension (RQ 5). Spiritual history taking was not found to have any effect on patient scores for spiritual well-being, quality of life, health care relationship trust,or pain (RQ 6). Finally, recruitment of GPs, early identification of palliative care patients, and patient-provider communication about end-of-life issues were major difficulties in our trial (RQ 7).line-height:115%">Conclusions: Health care providers generally perceive a palliative care process that focuses attention on the patients spirituality as a tough but rewarding experience. The FICA tool and the AMM are usable for the clinical assessment of spirituality, provided that they are used in a spontaneous way, according to the individual needs of the patient. These tools furnish greater insights into patients spiritual needs and resources and help caregivers to establish person-centred end-of-life care. More research is needed to better understand the role of the GP as spiritual caregiver, to design an interdisciplinarymodel for spiritual care in palliative home care and to develop and evaluate outcome measures for spiritual interventions.status: Publishe
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
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