ResearchPad - physicians https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Factors associated with visual outcomes after cataract surgery: A cross-sectional or retrospective study in Liberia]]> https://www.researchpad.co/article/elastic_article_15712 To report the initial outcomes and associated risk factors for poor outcome of cataract surgery performed in LiberiaMethods and analysisLV Prasad Eye Institute (LVPEI), Hyderabad, started providing eye care in Liberia since July 2017. Electronic Medical Records of 573 patients operated for age-related cataract from July 2017 to January 2019 were reviewed. One eye per patient was included for analysis. All patients underwent either phacoemulsification or manual small incision cataract surgery (MSICS). Pre and postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) were recorded at one day, 1–3 weeks and 4–11 weeks. Main outcome measure was BCVA at 4–11 weeks; Intraoperative complications and preoperative ocular comorbidities (POC) were noted. BCVA less than 6/12 was classified as visual impairment (VI). Risk factor for VI was analysed using the logistic regression model.ResultsOf the 573 patients, 288 were males and 285 were females (49.7%). Mean age was 65.9±10.9 years; 14.3% had POC. The surgical technique was mainly MSICS (94.59%, n = 542). At 4–11 weeks, good outcome of 6/12 or better was noted in 38.55% (UCVA) and 82.54% (BCVA). Visual acuity (VA) of 6/18 or better as UCVA and BCVA was noted in 63.5% and 88% eyes respectively. Poor outcome of less than 6/60 was noted as UCVA (11.11%) and BCVA (5.22%). Multivariable analysis showed poor visual outcomes significantly higher in patients with POC (odds ratio 3.28; 95% CI: 1.70, 6.34).ConclusionThe cataract surgical outcomes in Liberia were good; with ocular comorbidities as the only risk factor. ]]> <![CDATA[OtoMatch: Content-based eardrum image retrieval using deep learning]]> https://www.researchpad.co/article/elastic_article_14747 Acute infections of the middle ear are the most commonly treated childhood diseases. Because complications affect children’s language learning and cognitive processes, it is essential to diagnose these diseases in a timely and accurate manner. The prevailing literature suggests that it is difficult to accurately diagnose these infections, even for experienced ear, nose, and throat (ENT) physicians. Advanced care practitioners (e.g., nurse practitioners, physician assistants) serve as first-line providers in many primary care settings and may benefit from additional guidance to appropriately determine the diagnosis and treatment of ear diseases. For this purpose, we designed a content-based image retrieval (CBIR) system (called OtoMatch) for normal, middle ear effusion, and tympanostomy tube conditions, operating on eardrum images captured with a digital otoscope. We present a method that enables the conversion of any convolutional neural network (trained for classification) into an image retrieval model. As a proof of concept, we converted a pre-trained deep learning model into an image retrieval system. We accomplished this by changing the fully connected layers into lookup tables. A database of 454 labeled eardrum images (179 normal, 179 effusion, and 96 tube cases) was used to train and test the system. On a 10-fold cross validation, the proposed method resulted in an average accuracy of 80.58% (SD 5.37%), and maximum F1 score of 0.90 while retrieving the most similar image from the database. These are promising results for the first study to demonstrate the feasibility of developing a CBIR system for eardrum images using the newly proposed methodology.

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<![CDATA[Remote monitoring of clubfoot treatment with digital photographs in low resource settings: Is it accurate?]]> https://www.researchpad.co/article/elastic_article_14742 Clinical examination and functional assessment are often the first steps to assess outcome of clubfoot treatment. Clinical photographs may be an adjunct used to assess treatment outcomes in lower resourced settings where physical review by a specialist is limited. We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment.MethodsIn this single-centre diagnostic accuracy study, we included all children with clubfoot from a cohort treated between 2011 and 2013, in 2017. Two physiotherapists trained in clubfoot management calculated the Assessing Clubfoot Treatment (ACT) score for each child to decide if treatment was successful or if further treatment was required. Photographic images were then taken of 79 feet. Two blinded orthopaedic surgeons assessed three sets of images of each foot (n = 237 in total) at two time points (two months apart). Treatment for each foot was rated as ‘success’, ‘borderline’ or ‘failure’. Intra- and inter-observer variation for the photographic image was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the photographic image compared to the ACT score.ResultsThere was perfect correlation between clinical assessment and photographic evaluation of both raters at both time-points in 38 (48%) feet. The raters demonstrated acceptable reliability with re-scoring photographs (rater 1, k = 0.55; rater 2, k = 0.88). Thirty percent (n = 71) of photographs were assessed as poor quality image or sub-optimal patient position. Sensitivity of outcome with photograph compared to ACT score was 83.3%–88.3% and specificity ranged from 57.9%–73.3%.ConclusionDigital photography may help to confirm, but not exclude, success of clubfoot treatment. Future work to establish photographic parameters as an adjunct to assessing treatment outcomes, and guidance on a standardised protocol for photographs, may be beneficial in the follow up of children who have treated clubfoot in isolated communities or lower resourced settings. ]]> <![CDATA[Possible risk factors for poor asthma control assessed in a cross-sectional population-based study from Telemark, Norway]]> https://www.researchpad.co/article/elastic_article_13801 This cross-sectional study of the general population of Telemark County, Norway, aimed to identify risk factors associated with poor asthma control as defined by the Asthma Control Test (ACT), and to determine the proportions of patients with poorly controlled asthma who had undergone spirometry, used asthma medication, or been examined by a pulmonary physician. In 2014–2015, the study recruited 326 subjects aged 16–50 years who had self-reported physician-diagnosed asthma and presence of respiratory symptoms during the previous 12 months. The clinical outcome measures were body mass index (BMI), forced vital capacity (FVC) and forced expiratory volume in one second (FEV1), fractional exhaled nitric oxide (FeNO), immunoglobulin E (IgE) in serum and serum C-reactive protein (CRP). An ACT score ≤ 19 was defined as poorly controlled asthma. Overall, 113 subjects (35%) reported poor asthma control. The odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with poorly controlled asthma were: self-reported occupational exposure to vapor, gas, dust, or fumes during the previous 12 months (OR 2.0; 95% CI 1.1–3.6), body mass index ≥ 30 kg/m2 (OR 2.2; 95% CI 1.2–4.1), female sex (OR 2.6; 95% CI 1.5–4.7), current smoking (OR 2.8; 95% CI 1.5–5.3), and past smoking (OR 2.3; 95% CI 1.3–4.0). Poor asthma control was also associated with reduced FEV1 after bronchodilation (β –3.6; 95% CI –7.0 to –0.2). Moreover, 13% of the participants with poor asthma control reported no use of asthma medication, 51% had not been assessed by a pulmonary physician, and 20% had never undergone spirometry. Because these data are cross-sectional, further studies assessing possible risk factors in general and objectively measured occupational exposure in particular are needed. However, our results suggest that there is room for improvement with regards to use of spirometry and pulmonary physician referrals when a patient’s asthma is inadequately controlled.

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<![CDATA[The early experiences of Physician Associate students in the UK: A regional cross-sectional study investigating factors associated with engagement]]> https://www.researchpad.co/article/elastic_article_13815 The number of physician associates (PAs) training and working in the UK has increased over the last few years following the proliferation of postgraduate courses. Understanding early experiences and what impacts on engagement is important if we are to appropriately support this relatively new professional group.MethodsThis paper reports on a cross-sectional analysis of the first year of data from a prospective 10-year longitudinal cohort study. First year PA students (n = 89) were enrolled from five universities in one UK region where the training programmes were less than 2 years old. Data collected were: demographic information, wellbeing, burnout and engagement, expectations, placement experience, performance and caring responsibilities. Pearson’s correlations were used to examine relationships between variables and to select variables for a hierarchical regression analysis to understand which factors were associated with engagement. Descriptive statistics were calculated for questions relating to experience.ResultsThe experiences of PA students during their first 3–6 months were mixed. For example, 78.7% of students felt that there were staff on placement they could go to for support, however, 44.8% reported that staff did not know about the role and 61.3% reported that staff did not know what clinical work they should undertake. Regression analysis found that their level of engagement was associated with their perceived career satisfaction, overall well-being, and caring responsibilities.ConclusionsThe support systems required for PAs may need to be examined as results showed that the PA student demographic is different to that of medical students and caring responsibilities are highly associated with engagement. A lack of understanding around the PA role in clinical settings may also need to be addressed in order to better support and develop this workforce. ]]> <![CDATA[Implementation of maternity protection legislation: Gynecologists’ perceptions and practices in French-speaking Switzerland]]> https://www.researchpad.co/article/elastic_article_11226 In several countries, maternity protection legislations (MPL) confer an essential role to gynecologist-obstetricians (OBGYNs) for the protection of pregnant workers and their future children from occupational exposures. This study explores OBGYNs’ practices and difficulties in implementing MPL in the French-speaking part of Switzerland.MethodsAn online survey was sent to 333 OBGYNs. Data analysis included: 1) descriptive and correlational statistics and 2) hierarchical cluster analysis to identify patterns of practices.ResultsOBGYNs evoked several problems in MPL implementation: absence of risk analysis in the companies, difficult collaboration with employers, lack of competencies in the field of occupational health. Preventive leave was underused, with sick leave being prescribed instead. Training had a positive effect on OBGYNs’ knowledge and implementation of MPL. Hierarchical cluster analysis highlighted three main types of practices: 1) practice in line with legislation; 2) practice on a case-by-case basis; 3) limited practice. OBGYNs with good knowledge of MPL more consistently applied its provisions.ConclusionThe implementation of MPL appears challenging for OBGYNs. Collaboration with occupational physicians and training might help OBGYNs to better take on their role in maternity protection. MPL in itself could be improved. ]]> <![CDATA[A new simple brain segmentation method for extracerebral intracranial tumors]]> https://www.researchpad.co/article/Nb837d809-9647-425d-8dfd-2c3174a6dd80

Normal brain segmentation is available via FreeSurfer, Vbm, and Ibaspm software. However, these software packages cannot perform segmentation of the brain for patients with brain tumors. As we know, damage from extracerebral tumors to the brain occurs mainly by way of pushing and compressing while leaving the structure of the brain intact. Three-dimensional (3D) imaging, augmented reality (AR), and virtual reality (VR) technology have begun to be applied in clinical practice. The free medical open-source software 3D Slicer allows us to perform 3D simulations on a computer and requires little user interaction. Moreover, 3D Slicer can integrate with the third-party software mentioned above. The relationship between the tumor and surrounding brain tissue can be judged, but accurate brain segmentation cannot be performed using 3D Slicer. In this study, we combine 3D Slicer and FreeSurfer to provide a novel brain segmentation method for extracerebral tumors. This method can help surgeons identify the “real” relationship between the lesion and adjacent brain tissue before surgery and improve preoperative planning.

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<![CDATA[Multiple criteria decision analysis approach to consider therapeutic innovations in the emergency department: The methoxyflurane organizational impact in acute trauma pain]]> https://www.researchpad.co/article/N48fe9543-bf7a-4bb3-b7f3-098351efee5f

Background

Acute trauma pain is poorly managed in the emergency department (ED). The reasons are partly organizational: ED crowding and rare trauma care pathways contribute to oligoanalgesia. Anticipating the organizational impact of an innovative care procedure might facilitate the decision-making process and help to optimize pain management.

Methods

We used a multiple criteria decision analysis (MCDA) approach to consider the organizational impact of methoxyflurane (self-administered) in the ED, introduced alone or supported by a trauma care pathway. A MCDA experiment was designed for this specific context, 8 experts in emergency trauma care pathways (leading physicians and pharmacists working in French urban tertiary hospitals) were recruited. The study involved four steps: (i) Selection of organizational criteria for evaluating the innovation’s impact; (ii) assessment of the relative weight of each criterion; (iii) choice of appropriate scenarios for exploring the organizational impact of MEOX under various contexts; and (iv) software-assisted simulation based on pairwise comparisons of the scenarios. The final outcome measure was the expected overall organizational impact of methoxyflurane on a 0-to-100 scale (score >50: positive impact).

Results

Nine organizational criteria were selected. "Mean length of stay in the ED" was the most weighted. Methoxyflurane alone obtained 59 as a total score, with a putative positive impact for eight criteria, and a neutral effect on one. When a trauma care pathway was introduced concomitantly, the impact of methoxyflurane was greater overall (score: 75) and for each individual criterion.

Conclusions

Our model highlighted the putative positive organizational impact of methoxyflurane in the ED—particularly when supported by a trauma care pathway—and the relevance of expert consensus in this particular pharmacoeconomic context. The MCDA approach could be extended to other research fields and healthcare challenges in emergency medicine.

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<![CDATA[Microlearning for patient safety: Crew resource management training in 15-minutes]]> https://www.researchpad.co/article/5c8accebd5eed0c4849902fc

Objectives

We sought to establish the feasibility of chunking crew resource management (CRM) training into micro-size interventions and to compare different training approaches in the context of micro-learning.

Design

We evaluated whether participants in micro-learning CRM activities achieved learning objectives following training. In a between-subjects design, groups were observed for behaviour during a simulation that was part of a 15-minute modular intervention and tested for recollection afterwards.

Participants

The 129 participants recruited for this study were medical students, who already had relevant experience treating patients.

Interventions

The experimental setting involved three 5-minute components: video, simulation, and debriefing. Different groups viewed videos involving different didactic concepts: one group observed a videotaped concrete example of a medical care team applying a CRM tool (example group), and one group observed a videotaped lecture on the same topic (lecture group).

Main outcome measures

All simulations were videotaped and coded in detail for the occurrence of and time spent engaging in team behaviour and medical care. Questionnaires were administered before, immediately after, and two weeks after the intervention. We compared the groups’ behaviour during the simulation (team cooperation and medical care), retention of knowledge from the training content, and results of the evaluation.

Results

Both groups exhibited most of the behaviours included in the content of the instructional videos during the simulations and recollected information 2 weeks later. The example group exhibited significantly more of the training content during the simulation and demonstrated better retention 2 weeks later. Although the example group spent more time on team coordination, there was no difference in the number of executed medical measures.

Conclusion

Delivering CRM training in chunks of relatively short and highly standardised interventions appears feasible. In this study, the form of didactical presentation caused a difference in learning success between groups: a traditional lecture was outperformed by an instructional video demonstrating a practical example.

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<![CDATA[The effect of admitting fault versus shifting blame on expectations for others to do the same]]> https://www.researchpad.co/article/5c8acc40d5eed0c48498f2ed

A wealth of research has investigated how and why people cast blame. However, less is known about blame-shifting (i.e., blaming someone else for one’s own failures) and how exposure to a blame-shifting agent might lead to expectations that other agents will also shift blame. The present research tested whether exposure to a blame-shifting (versus responsibility-taking) agent would lead perceivers to expect a second, unrelated target to also shift blame. Contrary to our expectations, people expected greater blame-shifting after exposure to a responsible agent, particularly when perceivers were surprised by this reaction to failure. Discussion focuses on how people habitually expect some people to shift blame for their mishaps, and how expectancy violations when people act in unexpected ways predict the extent to which perceivers expect unrelated agents to also shift blame.

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<![CDATA[What can we learn by examining variations in the use of urine culture in the management of acute cystitis? A retrospective cohort study with linked administrative data in British Columbia, Canada, 2005-2011]]> https://www.researchpad.co/article/5c8c1954d5eed0c484b4d403

Introduction

Urinary tract infections (UTI) are common community-based bacterial infections. Empiric antibiotic recommendations are guided by local resistance rates. Previous research suggests that cultures are overused for uncomplicated cystitis, but practice patterns have not been described in detail. Variations in culturing have implications for the interpretation of antibiotic resistance rates.

Methods

We used a retrospective cohort study to analyze variations in urine culturing among physicians, controlling for patient and physician characteristics. We identified all outpatient physician visits among adults and children for cystitis in British Columbia between 2005 and 2011 using administrative data and linked these to laboratory data on urine cultures. Using hierarchical generalized linear mixed models we explored variations in urine culture submissions for cystitis (ICD code 595) and the associations with patient and physician characteristics, stratified by patient sex.

Results

Urine cultures were associated with 16% of visits for cystitis among females and 9% among males, and 59% of visits overall were associated with antibiotic treatment. Older patients, patients with a recent antibiotic prescription, and long term care residents were significantly less likely to have a culture associated with a cystitis visit, whether male or female. Female physicians and physicians with 16–35 years’ experience were more likely to culture, while international medical graduates were less likely–particularly for female visits. Notably, there was substantial unexplained variation among physicians after controlling for physician characteristics: we found a 24-fold variation in the odds of culturing a female UTI between physicians who were otherwise similar.

Conclusion

Individual physicians show substantial variation in their propensity to submit cultures for cystitis visits. Reducing such variation and encouraging appropriate levels of culturing would support effective antibiotic use.

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<![CDATA[Comparison of acute vertigo diagnosis and treatment practices between otolaryngologists and non-otolaryngologists: A multicenter scenario-based survey]]> https://www.researchpad.co/article/5c9902a2d5eed0c484b982b9

Acute vertigo is a common problem in emergency departments. However, clinical strategies of acute vertigo care vary among care providers. The aim of the study was to investigate differences in diagnosis [Dix-Hallpike test, the head impulse, nystagmus, and the test of skew (HINTS) procedure, and imaging modalities] and treatment (pharmacological treatments and the Epley maneuver) by otolaryngologists and non-otolaryngologists in emergency medicine settings. We used a multicenter case-based survey for the study. Four clinical vignettes of acute vertigo (posterior canal benign paroxysmal positional vertigo, vestibular neuritis, Meniere disease, and nonspecific vertigo) were used. Total 151 physicians from all study sites participated in the study. There were 84 non-otolaryngologists (48 emergency physicians and 36 internists) and 67 otolaryngologists. The multivariate analysis indicated that otolaryngologists ordered fewer CT scans (odds ratio (OR), 0.20; 95% confidence interval (CI), 0.07–0.53) and performed fewer HINTS procedures (OR, 0.17; 95% CI, 0.06–0.46), but used the Dix-Hallpike method more often (OR, 2.36; 95% CI, 1.01–5.52) for diagnosis compared to non-otolaryngologists. For treatment, otolaryngologists were less likely to use the Epley method (OR, 0.19; 95% CI, 0.07–0.53) and metoclopramide (OR, 0.09; 95% CI, 0.01–0.97) and more likely to use sodium bicarbonate (OR, 20.50; 95% CI, 6.85–61.40) compared to non-otolaryngologists. We found significant differences in the acute vertigo care provided by non-otolaryngologists and otolaryngologists from a vignette-based research. To improve acute vertigo care, educational systems focusing on acute vertigo are needed.

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<![CDATA[Utilization patterns of insulin for patients with type 2 diabetes from national health insurance claims data in South Korea]]> https://www.researchpad.co/article/5c89775bd5eed0c4847d2ad6

Type 2 diabetes mellitus (T2DM) is a chronic disease that requires long-term therapy and regular check-ups to prevent complications. In this study, insurance claim data from the National Health Insurance Service (NHIS) of Korea were used to investigate insulin use in T2DM patients according to the economic status of patients and their access to primary physicians, operationally defined as the frequently used medical care providers at the time of T2DM diagnosis. A total of 91,810 participants were included from the NHIS claims database for the period between 2002 and 2013. The utilization pattern of insulin was set as the dependent variable and classified as one of the following: non-use of antidiabetic drugs, use of oral antidiabetic drugs only, or use of insulin with or without oral antidiabetic drugs. The main independent variables of interest were level of income and access to a frequently-visited physician. Multivariate Cox proportional hazards analysis was performed. Insulin was used by 9,281 patients during the study period, while use was 2.874 times more frequent in the Medical-aid group than in the highest premium group [hazard ratio (HR): 2.874, 95% confidence interval (CI): 2.588–3.192]. Insulin was also used ~50% more often in the patients managed by a frequently-visited physician than in those managed by other healthcare professionals (HR: 1.549, 95% CI: 1.434–1.624). The lag time to starting insulin was shorter when the patients had a low income and no frequently-visited physicians. Patients with a low level of income were more likely to use insulin and to have a shorter lag time from diagnosis to starting insulin. The likelihood of insulin being used was higher when the patients had a frequently-visited physician, particularly if they also had a low level of income. Therefore, the economic statuses of patients should be considered to ensure effective management of T2DM. Utilizing frequently-visited physicians might improve the management of T2DM, particularly for patients with a low income.

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<![CDATA[Financial risk protection at the bedside: How Ethiopian physicians try to minimize out-of-pocket health expenditures]]> https://www.researchpad.co/article/5c6c7593d5eed0c4843cfec0

Background

Out-of-pocket health expenditures can pose major financial risks, create access-barriers and drive patients and families into poverty. Little is known about physicians’ role in financial protection of patients and families at the bedside in low-income settings and how they perceive their roles and duties when treating patients in a health care system requiring high out-of-pocket costs.

Objective

Assess physicians’ concerns regarding financial welfare of patients and their families and analyze physicians’ experiences in reducing catastrophic health expenditures for patients in Ethiopia.

Method

A national survey was conducted among physicians at 49 public hospitals in six regions in Ethiopia. Descriptive statistics were used.

Results

Totally 587 physicians responded (response rate 91%) and 565 filled the inclusion criteria. Health care costs driving people into financial crisis and poverty were witnessed by 82% of respondants, and 88% reported that costs for the patient are important when deciding to use or not use an intervention. Several strategies to save costs for patients were used: 37–79% of physicians were doing this daily or weekly through limiting prescription of drugs, limiting radiologic studies, ultrasound and lab tests, providing second best treatments, and avoiding admission or initiating early discharge. Overall, 75% of the physicians reported that ongoing and future costs to patients influenced their decisions to a greater extent than concerns for preserving hospital resources.

Conclusion

In Ethiopia, a low-income country aiming to move towards universal health coverage, physicians view themselves as both stewards of public resources, patient advocates and financial protectors of patients and their families. Their high concern for family welfare should be acknowledged and the economic and ethical implications of this practice must be further explored.

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<![CDATA[Patterns of Internet and smartphone use by parents of children with chronic kidney disease]]> https://www.researchpad.co/article/5c6c7597d5eed0c4843cfede

Background

Smartphones have become a part of universal technology by combining mobile and handheld functions, enabling expanded access to health information sources available on the Internet.

The purpose of this study was to describe the pattern of smartphones and Internet use to search for health information by parents of children with chronic kidney disease (CKD).

Methods

In a cross-sectional study, a questionnaire was applied to 111 parents of patients in a Brazilian pediatric nephrology center. Descriptive assessments were performed on Internet use patterns, and associative analyses were made of the influence of the smartphone use pattern on the search for health information.

Results

Of the 111 participants, 91% (101/111) accessed the Internet, 88% (89/101) searched for health information, and 90% (80/89) searched for CKD information. Smartphones were the most commonly used devices to access the Internet. There was no significant difference between age groups, schooling levels, places of residence and smartphone use to search information about CKD. Physicians continue to be primary sources of information (87%, 88/101), but now they share space with the Internet, which surpassed traditional sources such as books and other health professionals. There seems to be some discomfort on the part of the parents in admitting their research habit to the physician, considering that 65% (52/80) said they did not discuss the fact that they had looked for information on the Internet with their doctor. Obtaining more information about the disease and gaining knowledge regarding its complications were the main reasons that led to performing a search on the Internet, whose results were considered useful by 93% (74/80).

Conclusion

Parents of children with CKD have been using the Internet largely through smartphones to research about CKD, irrespective of age, schooling and place of residence. Given its wide use, the Internet can be an important vehicle for health education and contribute to providing the support needed by parents and patients to cope with the disease.

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<![CDATA[Technology enabled non-physician health workers extending telemedicine to rural homes to control hypertension and diabetes (TETRA): A pre-post demonstration project in Telangana, India]]> https://www.researchpad.co/article/5c75abfbd5eed0c484d07f6f

Objectives

We aimed to determine the feasibility and effectiveness of an intervention anchored on mHealth and task sharing strategy of involving non-physician health workers (NPHW) on population level detection, treatment and control of hypertension and diabetes in India.

Methods

Non-physician health workers (NPHWs) equipped with tablet computers that were linked with point-of-care devices for blood pressure (BP) and blood sugar measurements visited households, screened adult individuals for hypertension and diabetes from two randomly selected villages in the Medchal district, Telangana, India. Further, they digitally connected those individuals with hypertension and diabetes to a study physician via Skype, and handed over a printed e-prescription. Medication adherence checks, BP and fasting blood sugar measurements were done once a month and doctor consultations once in three months during follow-up.

Results

Among 2456 eligible individuals, 1751 and 1686 individuals were screened for hypertension and diabetes, respectively. Prevalence of hypertension was 23·6% (95% CI 21·6%-25·6%) and among them 38.9% were newly detected. Prevalence of diabetes was 11·2% (9·7%-12·7%) and 28.6% of them were newly detected. After 24 months of intervention, control of BP and blood sugar was achieved in 54.0% and 34·1% of individuals with hypertension and diabetes, respectively. Blood pressure control rate improved by 12% (7.9%-16.0%) in known hypertensive individuals over the intervention period.

Interpretation

This research demonstrates the feasibility and local acceptability of a mHealth intervention strategy anchored on NPHWs guided by physicians for detection, treatment and regular follow-up of individuals with hypertension and diabetes in a community setting in India.

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<![CDATA[The growing pains of physician-administration relationships in an academic medical center and the effects on physician engagement]]> https://www.researchpad.co/article/5c6dc9c0d5eed0c48452a138

Background

Physician engagement has become a key metric for healthcare leadership and is associated with better healthcare outcomes. However, engagement tends to be low and difficult to measure and improve. This study sought to efficiently characterize the professional cultural dynamics between physicians and administrators at an academic hospital and how those dynamics affect physician engagement.

Materials and methods

A qualitative mixed methods analysis was completed in 6 weeks, consisting of a preliminary analysis of the hospital system’s history that was used to purposefully recruit 20 physicians across specialties and 20 healthcare administrators across management levels for semi-structured interviews and observation. Participation rates of 77% (20/26) and 83% (20/24) were achieved for physicians and administrators, respectively. Cohorts consisted of equal numbers of men and women with experience ranging from 1 to 35 years within the organization. Field notes and transcripts were systematically analyzed using an iterative inductive-deductive approach. Emergent themes were presented and discussed with approximately 400 physicians and administrators within the organization to assess validity and which results were most meaningful.

Results & discussion

This investigation indicated a professional cultural disconnect was undermining efforts to improve physician engagement. This disconnect was further complicated by a minority (10%) not believing an issue existed and conflicting connotations not readily perceived by participants who often offered similar solutions. Physicians and administrators felt these results accurately reflected their realities and used this information as a common language to plan targeted interventions to improve physician engagement. Limitations of the study included its cross-sectional nature with a modest sample size at a single institution.

Conclusions

A qualitative mixed methods analysis efficiently identified professional cultural barriers within an academic hospital to serve as an institution-specific guide to improving physician engagement.

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<![CDATA[Hierarchical patient-centric caregiver network method for clinical outcomes study]]> https://www.researchpad.co/article/5c6dca0dd5eed0c48452a709

In clinical outcome studies, analysis has traditionally been performed using patient-level factors, with minor attention given to provider-level features. However, the nature of care coordination and collaboration between caregivers (providers) may also be important in determining patient outcomes. Using data from patients admitted to intensive care units at a large tertiary care hospital, we modeled the caregivers that provided medical service to a specific patient as patient-centric subnetwork embedded within larger caregiver networks of the institute. The caregiver networks were composed of caregivers who treated either a cohort of patients with particular disease or any patient regardless of disease. Our model can generate patient-specific caregiver network features at multiple levels, and we demonstrate that these multilevel network features, in addition to patient-level features, are significant predictors of length of hospital stay and in-hospital mortality.

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<![CDATA[The incidence of post-intubation hypertension and association with repeated intubation attempts in the emergency department]]> https://www.researchpad.co/article/5c6b266fd5eed0c484289a8b

Background

Studies in the non-emergency department (ED) settings have reported the relationships of post-intubation hypertension with poor patient outcomes. While ED-based studies have examined post-intubation hypotension and its sequelae, little is known about, post-intubation hypertension and its risk factors in the ED settings. In this context, we aimed to identify the incidence of post-intubation hypertension in the ED, and to test the hypothesis that repeated intubation attempts are associated with an increased risk of post-intubation hypertension.

Methods

This study is a secondary analysis of the data from a multicenter prospective observational study of emergency intubations in 15 EDs from 2012 through 2016. The analytic cohort comprised all adult non-cardiac-arrest patients undergoing orotracheal intubation without pre-intubation hypotension. The primary exposure was the repeated intubation attempts, defined as ≥2 laryngoscopic attempts. The outcome was post-intubation hypertension defined as an increase in systolic blood pressure (sBP) of >20% along with a post-intubation sBP of >160 mmHg. To investigate the association of repeated intubation attempts with the risk of post-intubation hypertension, we fit multivariable logistic regression models adjusting for ten potential confounders and patient clustering within the EDs.

Results

Of 3,097 patients, the median age was 69 years, 1,977 (64.0%) were men, and 991 (32.0%) underwent repeated intubation attempts. Post-intubation hypertension was observed in 276 (8.9%). In the unadjusted model, the incidence of post-intubation hypertension did not differ between the patients with single intubation attempt and those with repeated attempts (8.5% versus 9.8%, unadjusted P = 0.24). By contrast, after adjusting for potential confounders and patient clustering in the random-effects model, the patients who underwent repeated intubation attempts had a significantly higher risk of post-intubation hypertension (OR, 1.56; 95% CI, 1.11–2.18; adjusted P = 0.01).

Conclusions

We found that 8.9% of patients developed post-intubation hypertension, and that repeated intubation attempts were significantly associated with a significantly higher risk of post-intubation hypertension in the ED.

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<![CDATA[Non-cardiac chest pain patients in the emergency department: Do physicians have a plan how to diagnose and treat them? A retrospective study]]> https://www.researchpad.co/article/5c5df334d5eed0c484580ecd

Background

Non-cardiac chest pain is common and there is no formal recommendation on what diagnostic tests to use to identify underlying diseases after an acute coronary syndrome has been ruled out.

Objective

To evaluate the diagnostic tests, treatment recommendations and initiated treatments in patients presenting with non-cardiac chest pain to the emergency department (ED).

Methods

Single-center, retrospective medical chart review of patients presenting to the ED. Included were all medical records of patients aged 18 years and older presenting to the ED with chest pain and a non-cardiac discharge diagnosis between January 1, 2009 and December 31, 2011. Information on the diagnosis, diagnostic tests performed, treatment initiated and recommendation for further diagnostic testing or treatment were extracted. The primary outcomes of interest were the final diagnosis, diagnostic tests, and treatment recommendations. A formal ACS rule out testing was defined as serial three troponin testing.

Results

In total, 1341 ED admissions for non-cardiac chest pain (4.2% of all ED admissions) were analyzed. Non-specific chest pain remained the discharge diagnosis in 44.7% (n = 599). Identified underlying diseases included musculoskeletal chest pain (n = 602, 44.9%), pulmonary (n = 30, 2.2%), GI-tract (n = 35, 2.6%), or psychiatric diseases (n = 75, 5.6%). In 81.4% at least one troponin test and in 89% one ECG were performed. A formal ACS rule out troponin testing was performed in 9.2% (GI-tract disease 14.3%, non-specific chest pain 14.0%, pulmonary disease 10.0%, musculoskeletal chest pain 4.7%, and psychiatric disease 4.0%). Most frequently analgesics were prescribed (51%). A diagnostic test with proton pump inhibitor (PPI) was prescribed in 20% (mainly in gastrointestinal diseases). At discharge, over 72 different recommendations were given, ranging from no further measures to extensive cardiac evaluation.

Conclusion

In this retrospective study, a formal work-up to rule out ACS was found in a minority of patients presenting to the ED with chest pain of non-cardiac origin. A wide variation in diagnostic processes and treatment recommendations reflect the uncertainty of clinicians on how to approach patients after a cardiac cause was considered unlikely. Panic and anxiety disorders were rarely considered and a useful PPI treatment trial to diagnose gastroesophageal reflux disease was infrequently recommended.

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