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QUALITA' E MIGLIORAMENTO DELLA CONSULTAZIONE TELEFONICA MEDICA
No full textINTRODUZIONE
La consultazione telefonica medica (MTC) è diventata una parte integrante della moderna assistenza sanitaria. Alcuni studi mostrano che la qualità clinica della consultazione telefonica medica (MTC) è bassa e è dato sapere circa la qualità della MTC in Italia.
Nessuna revisione sistematica è attualmente disponibile per indirizzare la formazione dei sanitari sulla MTC.
I moderni sistemi informatici di supporto decisionale (CDSS) potrebbero svolgere un ruolo importante nel migliorare la qualità della MTC ma la loro efficacia non è chiara.
L'e-learning, l'integrazione tra programmi educativi e sistemi elettronici interattivi, potrebbe essere utile per formare i sanitari ma poco si sa circa la sua efficacia a confronto con la formazione tradizionale.
OBIETTIVI
1) Valutare la qualità clinica della MTC.
2) Revisionare la letteratura sull’efficacia di
- CDSS su mortalità e prevenzione della morbilità,
- e-learning in confronto con la formazione tradizionale,
- interventi formativi utili a migliorare le competenze telefoniche dei sanitari.
3) Testare l'efficacia e la sicurezza di un CDSS per il triage telefonico
4) Studiare le barriere e i facilitatori all'utilizzo dei CDSS.
METODI
E' stato condotto uno studio trasversale per rilevare la qualità della MTC; una revisione sistematica Cochrane off-topic è stato realizzata al fine di apprendere la metodologia Cochrane; tre revisioni sistematiche (due Cochrane) hanno reperito e combinato i risultati degli studi esistenti sull'efficacia dei CDSS in termini di mortalità e prevenzione della morbilità, di efficacia dell'e-learning a confronto con la formazione tradizionale e circa gli interventi formativi per il miglioramento delle abilità telefoniche dei sanitari; un trial controllato e randomizzato ha valutato l'efficacia e la sicurezza di un CDSS per triage telefonico e un altro studio trasversale ha valutato le barriere e i facilitatori verso l'utilizzo dei CDSS.
RISULTATI
La qualità clinica della MTC che è bassa perché i medici pongono solo circa il 30% delle domande obbligatorie.
L'uso del CDSS non influenza la mortalità ma presenta un effetto significativo sulla prevenzione della morbilità.
La revisione sistematica Cochrane off-topic ha mostrato che i due principali farmaci per la sclerosi multipla sono simili in termini di risultati tasso di recidiva, progressione e di risultati radiologici.
L'e-learning se confrontato con l'apprendimento tradizionale non migliora i risultati che il paziente trae dall'assistenza né i comportamenti dei sanitari; è possibile che porti ad un miglioramento leggermente minore delle competenze dei sanitari e non aumenti la loro conoscenza.
Non abbiamo trovato alcuno studio sugli interventi formativi per migliorare le abilità telefoniche dei sanitari.
A causa di problemi tecnici l'RCT che si proponeva di valutare l'efficacia di un CDSS per il triage telefonico non è riuscito a raccogliere risultati affidabili.
Sulla base del protocollo di studio su barriere e facilitatori all'uso dei CDSS, è stato condotto da altri ricercatori uno studio utile a progettare un modello per guidare l'adozione dei CDSS.
CONCLUSIONI
Nonostante il telefono sia uno strumento molto utilizzato, la qualità clinica della MTC in Italia sembra essere bassa. Le prove attualmente disponibili sul modo di affrontare il miglioramento delle abilità telefoniche dei sanitari sono scarse ma l'utilizzo dei CDSS ha dimostrato di essere efficace anche se l'efficacia e la sicurezza di CDSS specifici per la MTC rimangono da testare. Una volta disponibili prove di efficacia su come migliorare, l'e-learning sarà un canale formativo potenzialmente efficace come la formazione tradizionale, anche se può essere leggermente meno efficace nella trasmissione delle competenze.Background
The ability to consult by telephone has become an integral part of modern healthcare. Safety and legal concerns come from studies showing the clinical quality of medical telephone consultation (MTC) is low. Little is know about the quality of MTC in Italy.
No systematic review is currently available to address specific training of health professionals on MTC. Computerised decision support systems (CDSS) could play a role in improving MTC quality but their effectiveness is not clear, especially when CDSS are applied to telephone triage (clinical cases urgency estimate).
The e-learning, the integration between educational programmes and interactive electronic systems, could be useful to deliver these skills but little is known about its effectiveness in comparison with traditional training.
Objectives
1) To assess the clinical quality of MTC in a high MTC rate service.
2) To systematically review the literature on the efficacy of CDSS on mortality and morbidity prevention, e-learning in comparison with traditional learning, training intervention to improve clinicians telephone skills
3) To test the efficacy and safety of a CDSS for telephone triage in a high MTC rate service
4) To study barriers and facilitators toward the uptake of CDSS
Methods
A cross sectional study detected the MTC quality in a high MTC rate service; an off-topic Cochrane review was performed to learn Cochrane methodology; three systematic reviews (two Cochrane and one non-Cochrane) found and pooled the results of existing studies (estimating their risk of bias) about CDSS efficacy on mortality and morbidity prevention, about e-learning efficacy in comparison with traditional learning and about training intervention for telephone skills improvement; a randomised control trial assessed the efficacy and safety of a CDSS for telephone triage and one more cross sectional study addressed barriers and facilitators towards CDSS uptake.
Main results
The clinical quality of MTC in the study setting was low: doctors asked only about 30% of the obligatory questions.
CDSS use did not affect mortality but a significant effect was detected in the prevention of morbidity, even if selective outcome reporting and publication bias are not excluded.
The off-topic Cochrane systematic review showed the main two drugs for Multiple Sclerosis are similar in terms of relapse rate, progression and imaging outcomes.
E-learning when compared to traditional learning does not improve patient outcomes and health professionals behaviours; it possibly leads to slightly less improvement in health professionals skills but no difference on health professionals knowledge.
We found no evidence about training interventions for improving clinicians telephone communication skills on patient or clinicians outcomes.
Due to technical problems the RCT assessing the efficacy of a CDSS for telephone triage failed to collect reliable results: the CDSS could not be used to a sufficient extent and this resulted in a loss of power and a irreversible imbalance between the study arms.
The protocol about barriers and facilitators of CDSS uptake was performed in a study by the other researchers and they could design a model to guide the adoption of CDSS.
Authors' conclusions
Despite the phone is a very frequently used tool, the clinical quality of the MTC in Italy seems low. The currently available evidence on how to address the improvement of clinicians telephone skills is poor but CDSS proved to be effective even if specific CDSS for the MTC remain to be tested. Once evidence is available on how to improve, e-learning will be a potential cost-effective training way: it seems as effective as traditional training in terms of transmission of knowledge even if potentially little less effective on skills transmission
[Effectiveness of cognitive-associated with behavioral therapy psychopharmacological depression. Literature review meta-analyses]
No full textThe main focus is to analyze meta-analyses literature inherent the efficacy of cognitive behavioural therapy (CBT) with pharmacological therapy in the treatment of depression in adults rather than pharmacological therapy alone
[Assessment of a project for integrated management of care given to patients with type-2 diabetes in the Local Health Authority 21 of Legnago (Veneto Region, Northern Italy) in the period 2010-2012]
No full textOBIETTIVI: descrivere, nella ASL 21 di Legnago (VR), l'andamento di alcuni indicatori sanitari tra il 2009, anno precedente all'avvio di un progetto triennale per la gestione integrata dell'assistenza al paziente con diabete mellito di tipo 2, e il 2012, ultimo anno del progetto. DISEGNO: studio longitudinale trasversale ripetuto. SETTING E PARTECIPANTI: tutti i pazienti diabetici di tipo 2 della ASL 21, identificati nei database aziendali (in base a esenzioni per patologia, accessi al servizio diabetologico, consumo di farmaci antidiabetici e strisce per la determinazione della glicemia) e nelle cartelle cliniche dei medici di famiglia. PRINCIPALI MISURE DI OUTCOME: numero di test diagnostici e di follow-up erogati, consumo di farmaci, prestazioni specialistiche, accessi al pronto soccorso, ricoveri e mortalità. RISULTATI: nonostante un calo generalizzato (-3,1%) nei test erogati dalla ASL 21 ai suoi assistititi nel periodo 2009-2012, l'analisi ha documentato un marcato aumento per gli esami previsti nella gestione del diabete, quali curve da carico glicemico (+104,3%), emoglobina glicata (+19,0%) e microalbuminuria (+296,1%). I soggetti identificati come diabetici sono aumentati da 8.084 nel 2009 (5,2%) a 9.221 nel 2012 (5,9%). Sono stati osservati aumenti nella prevalenza di pazienti visitati presso un servizio diabetologico (dal 22,6% al 39,0%), nonché negli utilizzatori di metformina (dal 28,0% al 37,5%), insuline (dal 13,5% al 18,3%) e incretine (dall'1,4% al 9,0%). Il consumo di sulfaniluree è, invece, calato (dal 49,9% al 40,8%), come anche l'erogazione di alcune prestazioni specialistiche, gli accessi al pronto soccorso e i ricoveri, mentre il tasso di mortalità è rimasto stabile (29,6 decessi x1.000/anno). CONCLUSIONE: durante il periodo di implementazione del progetto sembra essersi verificato un aumento della sensibilità diagnostica e una maggiore presa in carico del paziente diabetico. Anche se la natura osservazionale dello studio non consente di dimostrare una relazione causa-effetto, i risultati sembrano supportare l'ipotesi che la gestione integrata della patologia migliori l'appropriatezza dell'assistenza
Analysis of patient safety culture in an out of hours primary care service.
No full textBackground: Aim of this study, part of a European collaborative research project, was to evaluate the "patient safety culture" (PSC) in a primary care out of hours service in order to provide the management with a baseline for improvement interventions. Methods: Cross sectional study with the administration of the Safety Attitude Questionnaire Ambulatory Version (SAQ-AV) administered to all the 56 doctors working out of hours in the ULSS 20 Verona Local Health Trust in April/May 2015. For each item of the questionnaire the average score, standard deviation, non-applicability, percentage of agreement, percentage of disagreement were calculated. Results: Doctors working out of hours appreciate the type of work, feel mutual trust and provide support to each other but only 63.6% would feel safe if they would be a patient; little attention to the rules, protocols and evidence-based practices, poor diffusion of culture to learn from the mistakes of other operators and the difficulty of speaking about the mistakes made were detected. Despite the positive perception of the work provided by the group, the doctors seem to feel that the morale of the operators is not optimal and their overall satisfaction is poor. Workload seems to be perceived as a minor issue, differently from the perception of a lack of attention by the management towards the service, lack of support, feedback and recognition, and the lack of reference points for the operators, risk management procedures, recently graduate staff training, equipment provision, regularity and correctness of drug and prescription supply, lack of and loss of essential information to make decisions and lack of communication leading to dysfunction of care. Conclusions: The questionnaire provides decision-makers with useful information about the patient safety culture, identifying critical areas to address improvement efforts
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
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Appropriate Similarity Measures for Author Cocitation Analysis
Full text linkWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Dispelling the Myths Behind First-author Citation Counts
Full text linkWe conducted a full-scale evaluative citation analysis study of scholars in the XML research field to explore just how different from each other author rankings resulting from different citation counting methods actually are, and to demonstrate the capability of emerging data and tools on the Web in supporting more realistic citation counting methods. Our results contest some common arguments for the continued
use of first-author citation counts in the evaluation of scholars, such as high correlations between author rankings by first-author citation counts and other citation
counting methods, and high costs of using more realistic citation counting methods that are not well-supported by the ISI databases. It is argued that increasingly available digital full text research papers make it possible for citation analysis studies to go beyond what the ISI databases have directly supported and to employ more
sophisticated methods
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