Acute Complex Care Model: An organizational approach for the medical care of hospitalized acute complex patients.

PubMed

Pietrantonio, Filomena; Orlandini, Francesco; Moriconi, Luca; La Regina, Micaela

2015-12-01

Chronic diseases are the major cause of death (59%) and disability worldwide, representing 46% of global disease burden. According to the Future Hospital Commission of the Royal College of Physicians, Medical Division (MD) will be responsible for all hospital medical services, from emergency to specialist wards. The Hospital Acute Care Hub will bring together the clinical areas of the MD that focus on the management of acute medical patients. The Chronic Care Model (CCM) places the patient at the center of the care system enhancing the community's social and health support, pathways and structures to keep chronic, frail, poly-pathological people at home or out of the hospital. The management of such patients in the hospital still needs to be solved. Hereby, we propose an innovative model for the management of the hospital's acute complex patients, which is the hospital counterpart of the CCM. The target population are acutely ill complex and poly-pathological patients (AICPPs), admitted to hospital and requiring high technology resources. The mission is to improve the management of medical admissions through pre-defined intra-hospital tracks and a global, multidisciplinary, patient-centered approach. The ACCM leader is an internal medicine specialist (IMS) who summarizes health problems, establishes priorities, and restores health balance in AICPPs. The epidemiological transition leading to a progressive increase in "chronically unstable" and complex patients needing frequent hospital treatment, inevitably enhances the role of hospital IMS in the coordination and delivery of care. ACCM represents a practical response to this epochal change of roles. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Risk Adjustment May Lessen Penalties On Hospitals Treating Complex Cardiac Patients Under Medicare's Bundled Payments.

PubMed

Markovitz, Adam A; Ellimoottil, Chandy; Sukul, Devraj; Mullangi, Samyukta; Chen, Lena M; Nallamothu, Brahmajee K; Ryan, Andrew M

2017-12-01

To reduce variation in spending, Medicare has considered implementing a cardiac bundled payment program for acute myocardial infarction and coronary artery bypass graft. Because the proposed program does not account for patient risk factors when calculating hospital penalties or rewards ("reconciliation payments"), it might unfairly penalize certain hospitals. We estimated the impact of adjusting for patients' medical complexity and social risk on reconciliation payments for Medicare beneficiaries hospitalized for the two conditions in the period 2011-13. Average spending per episode was $29,394. Accounting for medical complexity substantially narrowed the gap in reconciliation payments between hospitals with high medical severity (from a penalty of $1,809 to one of $820, or a net reduction of $989), safety-net hospitals (from a penalty of $217 to one of $87, a reduction of $130), and minority-serving hospitals (from a penalty of $70 to a reward of $56, an improvement of $126) and their counterparts. Accounting for social risk alone narrowed these gaps but had minimal incremental effects after medical complexity was accounted for. Risk adjustment may preserve incentives to care for patients with complex conditions under Medicare bundled payment programs.

Evaluation of pharmacotherapy complexity in residents of long-term care facilities: a cross-sectional descriptive study.

PubMed

Alves-Conceição, Vanessa; Silva, Daniel Tenório da; Santana, Vanessa Lima de; Santos, Edileide Guimarães Dos; Santos, Lincoln Marques Cavalcante; Lyra, Divaldo Pereira de

2017-07-25

Polypharmacy is a reality in long-term care facilities. However, number of medications used by the patient should not be the only predictor of a complex pharmacotherapy. Although the level of complexity of pharmacotherapy is considered an important factor that may lead to side effects, there are few studies in this field. The aim of this study was to evaluate the complexity of pharmacotherapy in residents of three long-term care facilities. A cross-sectional study was performed to evaluate the complexity of pharmacotherapy using the protocols laid out in the Medication Regimen Complexity Index instrument in three long-term care facilities in northeastern Brazil. As a secondary result, potential drug interactions, potentially inappropriate medications, medication duplication, and polypharmacy were evaluated. After the assessment, the association among these variables and the Medication Regimen Complexity Index was performed. In this study, there was a higher prevalence of women (64.4%) with a high mean age among the study population of 81.8 (±9.7) years. The complexity of pharmacotherapy obtained a mean of 15.1 points (±9.8), with a minimum of 2 and a maximum of 59. The highest levels of complexity were associated with dose frequency, with a mean of 5.5 (±3.6), followed by additional instructions of use averaging 4.9 (±3.7) and by the dosage forms averaging 4.6 (±3.0). The present study evaluated some factors that complicate the pharmacotherapy of geriatric patients. Although polypharmacy was implicated as a factor directly related to complexity, other indicators such as drug interactions, potentially inappropriate medications, and therapeutic duplication can also make the use of pharmacotherapy in such patients more difficult.

78 FR 58316 - Complex Issues in Developing Medical Devices for Pediatric Patients Affected by Rare Diseases...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-23

... DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration [Docket No. FDA-2013-N-1073] Complex Issues in Developing Medical Devices for Pediatric Patients Affected by Rare Diseases; Public Workshop; Request for Comments AGENCY: Food and Drug Administration, HHS. ACTION: Notice of public workshop...

Ethical and epistemic issues in direct-to-consumer drug advertising: where is patient agency?

PubMed

Womack, Catherine A

2013-05-01

Arguments for and against direct-to-consumer drug advertising (DTCA) center on two issues: (1) the epistemic effects on patients through access to information provided by the ads; and (2) the effects of such information on patients' abilities to make good choices in the healthcare marketplace. Advocates argue that DTCA provides useful information for patients as consumers, including information connecting symptoms to particular medical conditions, information about new drug therapies for those conditions. Opponents of DTCA point out substantial omissions in information provided by the ads and argue that the framing of the ads may mislead patients about the indications, uses, and effectiveness of the drugs advertised. They also suggest that DTCA has a number of potentially negative effects on the doctor-patient relationship. The standard arguments appear to assume a simplistic correlation-more information means more agency for patients. However, empirical studies on medical decision making suggest that this relationship is much more complex and nuanced. I examine recent research on ways in which patients are vulnerable with respect to DTCA. In order to address the complex issues of information acquisition and consumer decision-making in the health care marketplace, the focus should not be simply on what information patients need in order to make medical decisions, but also on the conditions under which patients actually are able to make medical decisions requiring complex medication information. This requires examining both the cognitive limitations of patients with respect to drug information and investigating patients' preferences and needs in a variety of medical contexts.

Medical decision and patient's preference: 'much ethics' and more trust always needed.

PubMed

Anyfantakis, Dimitrios; Symvoulakis, Emmanouil K

2011-01-01

There is much discussion on medical ethics literature regarding the importance of the patients' right for self-determination. We discuss some of the limitations of patient's autonomy with the aim to draw attention to the ethical complexity of medical decision making in the everyday clinical practice.

Working With Socially and Medically Complex Patients: When Care Transitions Are Circular, Overlapping, and Continual Rather Than Linear and Finite.

PubMed

Roberts, Shauna R; Crigler, Jane; Ramirez, Cristina; Sisco, Deborah; Early, Gerald L

2015-01-01

The care coordination program described here evolved from 5 years of trial and learning related to how to best serve our high-cost, high-utilizing, chronically ill, urban core patient population. In addition to medical complexity, they have daily challenges characteristic of persons served by Safety-Net health systems. Many have unstable health insurance status. Others have insecure housing. A number of patients have a history of substance use and mental illness. Many have fractured social supports. Although some of the best-known care transition models have been successful in reducing rehospitalizations and cost among patients studied, these models were developed for a relatively high functioning patient population with social support. We describe a successful approach targeted at working with patients who require a more intense and lengthy care coordination intervention to self-manage and reduce the cost of caring for their medical conditions. Using a diverse team and a set of replicable processes, we have demonstrated statistically significant reduction in the use of hospital and emergency services. Our intervention leverages the strengths and resilience of patients, focuses on trust and self-management, and targets heterogeneous "high-utilizer" patients with medical and social complexity.

A Systematic Review of Conceptual Frameworks of Medical Complexity and New Model Development.

PubMed

Zullig, Leah L; Whitson, Heather E; Hastings, Susan N; Beadles, Chris; Kravchenko, Julia; Akushevich, Igor; Maciejewski, Matthew L

2016-03-01

Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes. Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models. We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process. From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients' preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors. This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients.

Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care

PubMed Central

Loeb, Danielle F.; Binswanger, Ingrid A.; Candrian, Carey; Bayliss, Elizabeth A.

2015-01-01

PURPOSE Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. METHODS We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. RESULTS The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor—a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)—that complicated care for chronic medical illnesses. CONCLUSION This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. PMID:26371266

Primary care physician insights into a typology of the complex patient in primary care.

PubMed

Loeb, Danielle F; Binswanger, Ingrid A; Candrian, Carey; Bayliss, Elizabeth A

2015-09-01

Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology. We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach. The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor-a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)-that complicated care for chronic medical illnesses. This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients. © 2015 Annals of Family Medicine, Inc.

Eating disorder emergencies: understanding the medical complexities of the hospitalized eating disordered patient.

PubMed

Cartwright, Martina M

2004-12-01

Eating disorders are maladaptive eating behaviors that typically develop in adolescence and early adulthood. Psychiatric maladies and comorbid conditions, especially insulin-dependent diabetes mellitus, frequently co-exist with eating disorders. Serious medical complications affecting all organs and tissues can develop and result in numerous emergent hospitalizations. This article reviews the pathophysiologies of anorexia nervosa, bulimia nervosa, and orthorexia nervosa and discusses the complexities associated with the treatment of medical complications seen in these patients.

International patients on operation vacation: medical refuge and health system crisis Comment on "International patients on operation vacation - perspectives of patients travelling to Hungary for orthopaedic treatments".

PubMed

Lunt, Neil

2015-03-07

An understanding of patient mobility, international patients and medical tourism includes supply and demand side considerations. As well as micro-level reports of motivation and satisfaction we must acknowledge broader system-level dynamics. Exploring these may unearth more complex geographies of patient travel. © 2015 by Kerman University of Medical Sciences.

Medical Decision and Patient's Preference: 'Much Ethics' and More Trust Always Needed

PubMed Central

Anyfantakis, Dimitrios; Symvoulakis, Emmanouil K

2011-01-01

There is much discussion on medical ethics literature regarding the importance of the patients' right for self-determination. We discuss some of the limitations of patient's autonomy with the aim to draw attention to the ethical complexity of medical decision making in the everyday clinical practice. PMID:21647328

Can Mindfulness Training Improve Medication Adherence? Integrative Review of the Current Evidence and Proposed Conceptual Model.

PubMed

Salmoirago-Blotcher, Elena; Carey, Michael P

Medication adherence is a complex, multi-determined behavior that is often influenced by system- (e.g., cost), drug- (e.g., regimen complexity), and patient-related (e.g., depression) factors. System-level approaches (e.g., making medications more affordable) are critically important but do not address patient-level factors that can undermine adherence. In this paper, we identify patient-level determinants of non-adherence and discuss whether mindfulness-training approaches that target these determinants can help to improve adherence to medical treatment. We highlight two chronic medical conditions (viz., heart failure and HIV) where poor adherence is a significant concern, and examine the evidence regarding the use of mindfulness interventions to improve medication adherence in these two conditions. We also discuss the theoretical underpinnings of mindfulness training with respect to medication adherence, and conclude by suggesting directions for future research. Copyright © 2018 Elsevier Inc. All rights reserved.

Patient passports aim to speed appropriate care for medically complex children presenting to ED.

PubMed

2015-05-01

Mattel Children's Hospital at Ronald Reagan UCLA Medical Center in Los Angeles, CA, has developed a "patient passport" to improve the timely and appropriate care of medically complex children who present to the ED. The one-page form, which parents can keep in their wallets, highlights any special indications or sensitivities that the child has as well as contact information for the patient's primary care provider. The form also includes special instructions for the triage nurse. Creation of the tool was prompted by the parents who complained that their medically complex children were receiving different care in the ED than on the pediatric floor of the hospital. The tool was developed by a group comprised of parents, pediatric providers, and ED representatives. Physicians must create and sign the passports, either in the hospital or in their outpatient clinics, although parents may request a passport for their children.

Defining Team Effort Involved in Patient Care from the Primary Care Physician's Perspective.

PubMed

Hwang, Andrew S; Atlas, Steven J; Hong, Johan; Ashburner, Jeffrey M; Zai, Adrian H; Grant, Richard W; Hong, Clemens S

2017-03-01

A better understanding of the attributes of patients who require more effort to manage may improve risk adjustment approaches and lead to more efficient resource allocation, improved patient care and health outcomes, and reduced burnout in primary care clinicians. To identify and characterize high-effort patients from the physician's perspective. Cohort study. Ninety-nine primary care physicians in an academic primary care network. From a list of 100 randomly selected patients in their panels, PCPs identified patients who required a high level of team-based effort and patients they considered complex. For high-effort patients, PCPs indicated which factors influenced their decision: medical/care coordination, behavioral health, and/or socioeconomic factors. We examined differences in patient characteristics based on PCP-defined effort and complexity. Among 9594 eligible patients, PCPs classified 2277 (23.7 %) as high-effort and 2676 (27.9 %) as complex. Behavioral health issues were the major driver of effort in younger patients, while medical/care coordination issues predominated in older patients. Compared to low-effort patients, high-effort patients were significantly (P < 0.01 for all) more likely to have higher rates of medical (e.g. 23.2 % vs. 6.3 % for diabetes) and behavioral health problems (e.g. 9.8 % vs. 2.9 % for substance use disorder), more frequent primary care visits (10.9 vs. 6.0 visits), and higher acute care utilization rates (25.8 % vs. 7.7 % for emergency department [ED] visits and 15.0 % vs. 3.9 % for hospitalization). Almost one in five (18 %) patients who were considered high-effort were not deemed complex by the same PCPs. Patients defined as high-effort by their primary care physicians, not all of whom were medically complex, appear to have a high burden of psychosocial issues that may not be accounted for in current chronic disease-focused risk adjustment approaches.

Immunosuppressive therapy after solid-organ transplantation: does the INTERMED identify patients at risk of poor adherence?

PubMed Central

Michaud, Laurent; Ludwig, Gundula; Berney, Sylvie; Rodrigues, Stéphanie; Niquille, Anne; Santschi, Valérie; Favre, Anne-Sophie; Lange, Anne-Catherine; Michels, Annemieke A.; Vrijens, Bernard; Bugnon, Olivier; Pilon, Nathalie; Pascual, Manuel; Venetz, Jean-Pierre; Stiefel, Friedrich; Schneider, Marie-Paule

2016-01-01

Background: Lack of adherence to medication is a trigger of graft rejection in solid-organ transplant (SOT) recipients. Objective: This exploratory study aimed to assess whether a biopsychosocial evaluation using the INTERMED instrument before transplantation could identify SOT recipients at risk of suboptimal post-transplantation adherence to immunosuppressant drugs. We hypothesized that complex patients (INTERMED>20) might have lower medication adherence than noncomplex patients (INTERMED≤20). Methods: Each patient eligible for transplantation at the University Hospital of Lausanne, Switzerland, has to undergo a pre-transplantation psychiatric evaluation. In this context the patient was asked to participate in our study. The INTERMED was completed pre-transplantation, and adherence to immunosuppressive medication was monitored post-transplantation by electronic monitors for 12 months. The main outcome measure was the implementation and persistence to two calcineurin inhibitors, cyclosporine and tacrolimus, according to the dichotomized INTERMED score (>20 or ≤20). Results: Among the 50 SOT recipients who completed the INTERMED, 32 entered the study. The complex (N=11) and noncomplex patients (N=21) were similar in terms of age, sex and transplanted organ. Implementation was 94.2% in noncomplex patients versus 87.8% in complex patients (non-significant p-value). Five patients were lost to follow-up: one was non-persistent, and four refused electronic monitoring. Of the four patients who refused monitoring, two were complex and withdrew early, and two were noncomplex and withdrew later in the study. Conclusion: Patients identified as complex pre-transplant by the INTERMED tended to deviate from their immunosuppressant regimen, but the findings were not statistically significant. Larger studies are needed to evaluate this association further, as well as the appropriateness of using a nonspecific biopsychosocial instrument such as INTERMED in highly morbid patients who have complex social and psychological characteristics. PMID:28042353

Why do patients engage in medical tourism?

PubMed

Runnels, Vivien; Carrera, P M

2012-12-01

Medical tourism is commonly perceived and popularly depicted as an economic issue, both at the system and individual levels. The decision to engage in medical tourism, however, is more complex, driven by patients' unmet need, the nature of services sought and the manner by which treatment is accessed. In order to beneficially employ the opportunities medical tourism offers, and address and contain possible threats and harms, an informed decision is crucial. This paper aims to enhance the current knowledge on medical tourism by isolating the focal content of the decisions that patients make. Based on the existing literature, it proposes a sequential decision-making process in opting for or against medical care abroad, and engaging in medical tourism, including considerations of the required treatments, location of treatment, and quality and safety issues attendant to seeking care. Accordingly, it comments on the imperative of access to health information and the current regulatory environment which impact on this increasingly popular and complex form of accessing and providing medical care. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Aligning medication reconciliation and secure messaging: qualitative study of primary care providers' perspectives.

PubMed

Heyworth, Leonie; Clark, Justice; Marcello, Thomas B; Paquin, Allison M; Stewart, Max; Archambeault, Cliona; Simon, Steven R

2013-12-02

Virtual (non-face-to-face) medication reconciliation strategies may reduce adverse drug events (ADEs) among vulnerable ambulatory patients. Understanding provider perspectives on the use of technology for medication reconciliation can inform the design of patient-centered solutions to improve ambulatory medication safety. The aim of the study was to describe primary care providers' experiences of ambulatory medication reconciliation and secure messaging (secure email between patients and providers), and to elicit perceptions of a virtual medication reconciliation system using secure messaging (SM). This was a qualitative study using semi-structured interviews. From January 2012 to May 2012, we conducted structured observations of primary care clinical activities and interviewed 15 primary care providers within a Veterans Affairs Healthcare System in Boston, Massachusetts (USA). We carried out content analysis informed by the grounded theory. Of the 15 participating providers, 12 were female and 11 saw 10 or fewer patients in a typical workday. Experiences and perceptions elicited from providers during in-depth interviews were organized into 12 overarching themes: 4 themes for experiences with medication reconciliation, 3 themes for perceptions on how to improve ambulatory medication reconciliation, and 5 themes for experiences with SM. Providers generally recognized medication reconciliation as a valuable component of primary care delivery and all agreed that medication reconciliation following hospital discharge is a key priority. Most providers favored delegating the responsibility for medication reconciliation to another member of the staff, such as a nurse or a pharmacist. The 4 themes related to ambulatory medication reconciliation were (1) the approach to complex patients, (2) the effectiveness of medication reconciliation in preventing ADEs, (3) challenges to completing medication reconciliation, and (4) medication reconciliation during transitions of care. Specifically, providers emphasized the importance of medication reconciliation at the post-hospital visit. Providers indicated that assistance from a caregiver (eg, a family member) for medication reconciliation was helpful for complex or elderly patients and that patients' social or cognitive factors often made medication reconciliation challenging. Regarding providers' use of SM, about half reported using SM frequently, but all felt that it improved their clinical workflow and nearly all providers were enthusiastic about a virtual medication reconciliation system, such as one using SM. All providers thought that such a system could reduce ADEs. Although providers recognize the importance and value of ambulatory medication reconciliation, various factors make it difficult to execute this task effectively, particularly among complex or elderly patients and patients with complicated social circumstances. Many providers favor enlisting the support of pharmacists or nurses to perform medication reconciliation in the outpatient setting. In general, providers are enthusiastic about the prospect of using secure messaging for medication reconciliation, particularly during transitions of care, and believe a system of virtual medication reconciliation could reduce ADEs.

Patient safety and technology-driven medication - A qualitative study on how graduate nursing students navigate through complex medication administration.

PubMed

Orbæk, Janne; Gaard, Mette; Fabricius, Pia; Lefevre, Rikke S; Møller, Tom

2015-05-01

The technology-driven medication process is complex, involving advanced technologies, patient participation and increased safety measures. Medication administration errors are frequently reported, with nurses implicated in 26-38% of in-hospital cases. This points to the need for new ways of educating nursing students in today's medication administration. To explore nursing students' experiences and competences with the technology-driven medication administration process. 16 pre-graduate nursing students were included in two focus group interviews which were recorded, transcribed and analyzed using the systematic horizontal phenomenological-hermeneutic template methodology. The interviews uncovered that understanding the technologies; professionalism and patient safety are three crucial elements in the medication process. The students expressed positivity and confidence in using technology, but were fearful of committing serious medication errors. From the nursing students' perspective, experienced nurses deviate from existing guidelines, leaving them feeling isolated in practical learning situations. Having an unclear nursing role model for the technology-driven medication process, nursing students face difficulties in identifying and adopting best practices. The impact of using technology on the frequency, type and severity of medication errors; the technologies implications on nursing professionalism and the nurses ability to secure patient adherence to the medication process, still remains to be studied. Copyright © 2014 Elsevier Ltd. All rights reserved.

[Isolation of Sporothrix pallida complex in clinical and environmental samples from Chile].

PubMed

Cruz Choappa, Rodrigo M; Vieille Oyarzo, Peggy I; Carvajal Silva, Laura C

2014-01-01

The isolation of S. pallida complex from medical samples and home garden soil of a patient in Chile is here in reported. Fungi of the Sporothrix schenckii complex can cause various infections. In Chile, the medical and environmental isolates of these this complex are rare. The aim of this study was to identify an unusual agent in a case of onychomycosis and to detect its presence in the patient's home garden. For this purpose, clinical samples were obtained by scraping the patient's subungueal first right toe nail as well as by taking soil samples from different areas of her home garden. Species identification was performed by morphophysiology and one of the strains isolated from the patient's toe nail was sent to CBS for molecular confirmation (14.062). S. pallida complex was identified both from the patient's toe nail and samples taken from her home garden. Copyright © 2014 Asociación Argentina de Microbiología. Publicado por Elsevier España. All rights reserved.

Pseudogynecomastia after massive weight loss: detectability of technique, patient satisfaction, and classification.

PubMed

Gusenoff, Jeffrey A; Coon, Devin; Rubin, J Peter

2008-11-01

An increasing number of male patients are presenting for treatment of male chest deformity after massive weight loss. The authors prefer to preserve the nipple-areola complex on a dermoglandular pedicle. They sought to identify detectability of technique, assess patient satisfaction, and outline a treatment algorithm for this population. Ten male massive weight loss patients underwent chest-contouring procedures over a period of 6 years and were surveyed to identify satisfaction with reconstruction. Preoperative photographs were used to devise a classification system. Twenty-seven medical professionals evaluated and rated digital photographs of the patients. Eight patients had pedicled reconstructions and two had free-nipple grafts. Mean age was 42.9 +/- 9.5 years, mean pre-weight loss body mass index was 54.1 +/- 10.6, post-weight loss body mass index was 29.4 +/- 4.5, and mean change in body mass index was 24.8 +/- 9.7. All patients would have surgery again, nine would recommend it to a friend, six would go shirtless in public, nine reported no loss of nipple sensation, and three reported dysesthesias of the nipple-areola complex. Medical professionals reproducibly associated poor wound healing with free-nipple grafting and rated poorly positioned nipple-areola complexes with low aesthetic scores. Medical professional scores for chest contour and nipple-areola complex aesthetics did not correlate with technique and were lower than scores provided by the patients. Patient satisfaction for treatment of the male chest deformity after massive weight loss is high. In carefully selected patients, preservation of the nipple-areola complex on a dermoglandular pedicle can aid in achieving an optimal aesthetic result.

Rethinking the outpatient medication list: increasing patient activation and education while architecting for centralization and improved medication reconciliation.

PubMed

Pandolfe, Frank; Wright, Adam; Slack, Warner V; Safran, Charles

2018-05-17

Identify barriers impacting the time consuming and error fraught process of medication reconciliation. Design and implement an electronic medication management system where patient and trusted healthcare proxies can participate in establishing and maintaining an inclusive and up-to-date list of medications. A patient-facing electronic medication manager was deployed within an existing research project focused on elder care management funded by the AHRQ, InfoSAGE, allowing patients and patients' proxies the ability to build and maintain an accurate and up-to-date medication list. Free and open-source tools available from the U.S. government were used to embed the tenets of centralization, interoperability, data federation, and patient activation into the design. Using patient-centered design and free, open-source tools, we implemented a web and mobile enabled patient-facing medication manager for complex medication management. Patient and caregiver participation are essential to improve medication safety. Our medication manager is an early step towards a patient-facing medication manager that has been designed with data federation and interoperability in mind.

Associations among medication regimen complexity, medical specialty, and medication possession ratio in newly diagnosed hypertensive patients

PubMed Central

Ho, Chen-Pei; Yeh, Jih-I; Wen, Shu-Hui; Lee, Tony Jer-Fu

2017-01-01

Abstract The aim of this study was to explore the associations among the medication regimen complexity index (MRCI), medical specialty, and medication possession ratio (MPR) in newly diagnosed hypertensive patients. Data from 19,859 newly diagnosed hypertensive patients were collected from 2,000,000 random samples of the National Health Insurance Research Database in Taiwan. All study participants were followed for 1 year after the first diagnosis of hypertension. MPR was defined as total days of antihypertensive drugs supplied/365 days. MRCI was calculated on the basis of the type of dosage forms, dosing frequency, and additional directions for use of antihypertensive drugs. Patients were further restricted to those who visited the same medical specialty to examine specialty-specific variations in the MRCI and MPR. The mean MPR was 54.83%, and the sample sizes for the low-, medium-, and high-MPR groups were 9806 (49.38%), 4619 (23.26%), and 5434 (27.36%), respectively. More than 50% of the patients visited the same medical specialty during the 1-year follow-up. The mean MRCI was 3.64; the cardiology specialty had the highest MRCI, and the family medicine specialty had the lowest. Multiple linear regression analyses showed that MRCI was negatively associated with MPR (β = −7.75, P ≤ .01) whether or not the patients visited the same medical specialty. For the patients who visited the same medical specialty, those treated by endocrinology and metabolism specialists had a significantly higher MPR (β = 9.87, P ≤ .01) than that of those treated by family medicine specialists. MRCI and medical specialty were both significantly associated with the MPR of newly diagnosed hypertensive patients. PMID:29137042

Discharge summary for medically complex infants transitioning to primary care.

PubMed

Peacock, Jennifer J

2014-01-01

Improvements in the care of the premature infant and advancements in technology are increasing life expectancy of infants with medical conditions once considered lethal; these infants are at risk of becoming a medically complex infant. Complex infants have a significant existing problem list, are on several medications, and receive medical care by several specialists. Deficits in communication and information transfer at the time of discharge remain problematic for this population. A questionnaire was developed for primary care providers (PCPs) to explore the effectiveness of the current discharge summary because it is related to effective communication when assuming the care of a new patient with medical complexity. PCPs assuming the care of these infants agree that an evidence-based tool, in the form of a specialized summary for this population, would be of value.

Implementation of an Interorganizational System: The Case of Medical Insurance E-Clearance

ERIC Educational Resources Information Center

Bose, Indranil; Liu, Han; Ye, Alex

2012-01-01

The patients receiving treatment from a hospital need to interact with multiple entities when claiming reimbursements. The complexities of the medical service supply chain can be simplified with an electronic clearance management system that allows hospitals, medical insurance bureau, bank, and patients to interact in a seamless and cashless…

Value-Based Insurance Design Benefit Offsets Reductions In Medication Adherence Associated With Switch To Deductible Plan.

PubMed

Reed, Mary E; Warton, E Margaret; Kim, Eileen; Solomon, Matthew D; Karter, Andrew J

2017-03-01

Enrollment in high-deductible health plans is increasing out-of-pocket spending. But innovative plans that pair deductibles with value-based insurance designs can help preserve low-cost access to high-value treatments for patients by aligning coverage with clinical value. Among adults in high-deductible health plans who were prescribed medications for chronic conditions, we examined what impact a value-based pharmacy benefit that offered free chronic disease medications had on medication adherence. Overall, we found that the value-based plan offset reductions in medication adherence associated with switching to a deductible plan. The value-based plan appeared particularly beneficial for patients who started with low levels of medication adherence. Patients with additional clinical complexity or vulnerable populations living in neighborhoods with lower socioeconomic status, however, did not show adherence improvements and might not be taking advantage of value-based insurance design provisions. Additional efforts may be needed to educate patients about their nuanced benefit plans to help overcome initial confusion about these complex plans. Project HOPE—The People-to-People Health Foundation, Inc.

Factors Associated With Having a Physician, Nurse Practitioner, or Physician Assistant as Primary Care Provider for Veterans With Diabetes Mellitus

PubMed Central

Morgan, Perri; Everett, Christine M.; Smith, Valerie A.; Woolson, Sandra; Edelman, David; Hendrix, Cristina C.; Berkowitz, Theodore S. Z.; White, Brandolyn; Jackson, George L.

2017-01-01

Expanded use of nurse practitioners (NPs) and physician assistants (PAs) is a potential solution to workforce issues, but little is known about how NPs and PAs can best be used. Our study examines whether medical and social complexity of patients is associated with whether their primary care provider (PCP) type is a physician, NP, or PA. In this national retrospective cohort study, we use 2012-2013 national Veterans Administration (VA) electronic health record data from 374 223 veterans to examine whether PCP type is associated with patient, clinic, and state-level factors representing medical and social complexity, adjusting for all variables simultaneously using a generalized logit model. Results indicate that patients with physician PCPs are modestly more medically complex than those with NP or PA PCPs. For the group having a Diagnostic Cost Group (DCG) score >2.0 compared with the group having DCG <0.5, odds of having an NP or a PA were lower than for having a physician PCP (NP odds ratio [OR] = 0.83, 95% confidence interval [CI]: 0.79-0.88; PA OR = 0.85, CI: 0.80-0.89). Social complexity is not consistently associated with PCP type. Overall, we found minor differences in provider type assignment. This study improves on previous work by using a large national dataset that accurately ascribes the work of NPs and PAs, analyzing at the patient level, analyzing NPs and PAs separately, and addressing social as well as medical complexity. This is a requisite step toward studies that compare patient outcomes by provider type. PMID:28617196

Factors Associated With Having a Physician, Nurse Practitioner, or Physician Assistant as Primary Care Provider for Veterans With Diabetes Mellitus.

PubMed

Morgan, Perri; Everett, Christine M; Smith, Valerie A; Woolson, Sandra; Edelman, David; Hendrix, Cristina C; Berkowitz, Theodore S Z; White, Brandolyn; Jackson, George L

2017-01-01

Expanded use of nurse practitioners (NPs) and physician assistants (PAs) is a potential solution to workforce issues, but little is known about how NPs and PAs can best be used. Our study examines whether medical and social complexity of patients is associated with whether their primary care provider (PCP) type is a physician, NP, or PA. In this national retrospective cohort study, we use 2012-2013 national Veterans Administration (VA) electronic health record data from 374 223 veterans to examine whether PCP type is associated with patient, clinic, and state-level factors representing medical and social complexity, adjusting for all variables simultaneously using a generalized logit model. Results indicate that patients with physician PCPs are modestly more medically complex than those with NP or PA PCPs. For the group having a Diagnostic Cost Group (DCG) score >2.0 compared with the group having DCG <0.5, odds of having an NP or a PA were lower than for having a physician PCP (NP odds ratio [OR] = 0.83, 95% confidence interval [CI]: 0.79-0.88; PA OR = 0.85, CI: 0.80-0.89). Social complexity is not consistently associated with PCP type. Overall, we found minor differences in provider type assignment. This study improves on previous work by using a large national dataset that accurately ascribes the work of NPs and PAs, analyzing at the patient level, analyzing NPs and PAs separately, and addressing social as well as medical complexity. This is a requisite step toward studies that compare patient outcomes by provider type.

Using a Clinical Knowledge Base to Assess Comorbidity Interrelatedness Among Patients with Multiple Chronic Conditions.

PubMed

Zulman, Donna M; Martins, Susana B; Liu, Yan; Tu, Samson W; Hoffman, Brian B; Asch, Steven M; Goldstein, Mary K

2015-01-01

Decision support tools increasingly integrate clinical knowledge such as medication indications and contraindications with electronic health record (EHR) data to support clinical care and patient safety. The availability of this encoded information and patient data provides an opportunity to develop measures of clinical decision complexity that may be of value for quality improvement and research efforts. We investigated the feasibility of using encoded clinical knowledge and EHR data to develop a measure of comorbidity interrelatedness (the degree to which patients' co-occurring conditions interact to generate clinical complexity). Using a common clinical scenario-decisions about blood pressure medications in patients with hypertension-we quantified comorbidity interrelatedness by calculating the number of indications and contraindications to blood pressure medications that are generated by patients' comorbidities (e.g., diabetes, gout, depression). We examined properties of comorbidity interrelatedness using data from a decision support system for hypertension in the Veterans Affairs Health Care System.

Pain medication management processes used by oncology outpatients and family caregivers part I: health systems contexts.

PubMed

Schumacher, Karen L; Plano Clark, Vicki L; West, Claudia M; Dodd, Marylin J; Rabow, Michael W; Miaskowski, Christine

2014-11-01

Oncology patients with persistent pain treated in outpatient settings and their family caregivers have significant responsibility for managing pain medications. However, little is known about their practical day-to-day experiences with pain medication management. The aim was to describe day-to-day pain medication management from the perspectives of oncology outpatients and their family caregivers who participated in a randomized clinical trial of a psychoeducational intervention called the Pro-Self(©) Plus Pain Control Program. In this article, we focus on pain medication management by patients and family caregivers in the context of multiple complex health systems. We qualitatively analyzed audio-recorded intervention sessions that included extensive dialogue between patients, family caregivers, and nurses about pain medication management during the 10-week intervention. The health systems context for pain medication management included multiple complex systems for clinical care, reimbursement, and regulation of analgesic prescriptions. Pain medication management processes particularly relevant to this context were getting prescriptions and obtaining medications. Responsibilities that fell primarily to patients and family caregivers included facilitating communication and coordination among multiple clinicians, overcoming barriers to access, and serving as a final safety checkpoint. Significant effort was required of patients and family caregivers to insure safe and effective pain medication management. Health systems issues related to access to needed analgesics, medication safety in outpatient settings, and the effort expended by oncology patients and their family caregivers require more attention in future research and health-care reform initiatives. Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Moving into the 'patient-centred medical home': reforming Australian general practice.

PubMed

Hayes, Paul; Lynch, Anthony; Stiffe, Jenni

2016-09-01

The Australian healthcare system is a complex network of services and providers funded and administered by federal, state and territory governments, supplemented by private health insurance and patient contributions. The broad geographical range, complexity and increasing demand within the Australian healthcare sector mean health expenditure is high. Aspects of current funding for the healthcare system have attracted criticism from medical practitioners, patients, representative organisations and independent statutory agencies. In response to the problems in primary care funding in Australia, The Royal Australian College of General Practitioners developed the Vision for general practice and a sustainable healthcare system (the Vision). The Vision presents a plan to improve healthcare delivery in Australia through greater quality, access and efficiency by reorienting how general practice services are funded based on the 'patient-centred medical home' model.

Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study.

PubMed

Eton, David T; Ramalho de Oliveira, Djenane; Egginton, Jason S; Ridgeway, Jennifer L; Odell, Laura; May, Carl R; Montori, Victor M

2012-01-01

Burden of treatment refers to the workload of health care as well as its impact on patient functioning and well-being. We set out to build a conceptual framework of issues descriptive of burden of treatment from the perspective of the complex patient, as a first step in the development of a new patient-reported measure. We conducted semistructured interviews with patients seeking medication therapy management services at a large, academic medical center. All patients had a complex regimen of self-care (including polypharmacy), and were coping with one or more chronic health conditions. We used framework analysis to identify and code themes and subthemes. A conceptual framework of burden of treatment was outlined from emergent themes and subthemes. Thirty-two patients (20 female, 12 male, age 26-85 years) were interviewed. Three broad themes of burden of treatment emerged including: the work patients must do to care for their health; problem-focused strategies and tools to facilitate the work of self-care; and factors that exacerbate the burden felt. The latter theme encompasses six subthemes including challenges with taking medication, emotional problems with others, role and activity limitations, financial challenges, confusion about medical information, and health care delivery obstacles. We identified several key domains and issues of burden of treatment amenable to future measurement and organized them into a conceptual framework. Further development work on this conceptual framework will inform the derivation of a patient-reported measure of burden of treatment.

Frequency and types of the medication errors in an academic emergency department in Iran: The emergent need for clinical pharmacy services in emergency departments.

PubMed

Zeraatchi, Alireza; Talebian, Mohammad-Taghi; Nejati, Amir; Dashti-Khavidaki, Simin

2013-07-01

Emergency departments (EDs) are characterized by simultaneous care of multiple patients with various medical conditions. Due to a large number of patients with complex diseases, speed and complexity of medication use, working in under-staffing and crowded environment, medication errors are commonly perpetrated by emergency care providers. This study was designed to evaluate the incidence of medication errors among patients attending to an ED in a teaching hospital in Iran. In this cross-sectional study, a total of 500 patients attending to ED were randomly assessed for incidence and types of medication errors. Some factors related to medication errors such as working shift, weekdays and schedule of the educational program of trainee were also evaluated. Nearly, 22% of patients experienced at least one medication error. The rate of medication errors were 0.41 errors per patient and 0.16 errors per ordered medication. The frequency of medication errors was higher in men, middle age patients, first weekdays, night-time work schedules and the first semester of educational year of new junior emergency medicine residents. More than 60% of errors were prescription errors by physicians and the remaining were transcription or administration errors by nurses. More than 35% of the prescribing errors happened during the selection of drug dose and frequency. The most common medication errors by nurses during the administration were omission error (16.2%) followed by unauthorized drug (6.4%). Most of the medication errors happened for anticoagulants and thrombolytics (41.2%) followed by antimicrobial agents (37.7%) and insulin (7.4%). In this study, at least one-fifth of the patients attending to ED experienced medication errors resulting from multiple factors. More common prescription errors happened during ordering drug dose and frequency. More common administration errors included dug omission or unauthorized drug.

Documentation of Functional Medication Management in Older Adults: A Retrospective Chart Review in Acute Care Hospitalization.

PubMed

Bolina, Monika; Jones, C Allyson; Koshman, Sheri; Heintz, Erin; Sadowski, Cheryl A

2016-12-01

Functional skills can affect the ability of older adults to appropriately manage their medication regimens. Research evaluating a patient's functional ability or the assessment of medication management is limited. Our objective was to describe the documented components of functional medication management (FMM) in adults aged ≥65 years during an acute hospital stay. The secondary objective was to describe the characteristics of the healthcare providers (HCP) who document FMM. This study was a retrospective chart review of a sample of patients aged ≥65 years admitted to medical units in a tertiary hospital from January 2013 to October 2014. FMM was defined as the steps required to take medications-including ordering, picking up, organizing, preparing, administering, and monitoring medications-and the functional abilities necessary to perform these tasks. The mean (standard deviation [SD]) age of patients was 78.9 (8.4) years; 72 (52 %) were female. Of the 190 charts screened, 140 were eligible for inclusion. The mean (SD) number of documented scheduled oral medications was eight (3.1) per patient, and 108 (77.1 %) charts contained documented FMM-related information. Commonly documented FMM components included whether the patient could administer medications independently (73 [52 %]) or schedule medication (46 [33 %]). These activities were most frequently documented by physicians (124 [39 %]) and occupational therapists (108 [34 %]). FMM assessments for older adult inpatients with multiple comorbidities and complex medication regimens were not documented comprehensively or frequently. Given the complexity of medication regimens and the functional skills required to manage medications at home, failing to document these assessments when evaluating patients in hospital reflects a lost opportunity.

Parental health literacy and its impact on patient care.

PubMed

Scotten, Mitzi

2015-03-01

The process of navigating through the modern American health care system is becoming progressively challenging. The range of tasks being asked of patients in the digital age is vast and complex and includes completing intricate insurance applications, signing complex consent forms, and translating medical data and prescription medication directions. Nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely offered by medical providers. Mounting evidence now supports a growing awareness that general health literacy is the greatest individual factor affecting a person's health status. Copyright © 2015 Elsevier Inc. All rights reserved.

Enhanced Critical Care Air Transport Team Training for Mitigation of Task Saturation

DTIC Science & Technology

2013-03-01

specialized members (physician, critical care nurse , and respiratory therapist) trained to handle the complex, critical nature of patients in hemodynamic ...with complex medical conditions have been poorly studied. 3.0 BACKGROUND Teams are composed of three medical personnel (a physician, a nurse , and

Anticoagulant treatment of medical patients with complex clinical conditions.

PubMed

Ruiz-Ruiz, F; Medrano, F J; Santos-Lozano, J M; Rodríguez-Torres, P; Navarro-Puerto, A; Calderón, E J

2018-06-12

There is scarce available information on the treatment or prophylaxis with anticoagulant drugs of outpatients with medical diseases and complex clinical conditions. There are no clinical practice guidelines and/or specific recommendations for this patient subgroup, which are frequently treated by internists. Complex clinical conditions are those in which, due to comorbidity, age, vital prognosis or multiple treatment with drugs, a clinical situation arises of disease-disease, disease-drug or drug-drug interactions that is not included within the scenarios that commonly generate the scientific evidence. The objective of this narrative review is collecting and adapting of the clinical guidelines recommendations and systematic reviews to complex clinical conditions, in which the direct application of recommendations based on studies that do not include patients with this complexity and comorbidity could be problematic. Copyright © 2018 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.

Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors.

PubMed

Smith, Kenneth J; Handler, Steven M; Kapoor, Wishwa N; Martich, G Daniel; Reddy, Vivek K; Clark, Sunday

2016-07-01

This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients. © The Author(s) 2015.

Cancer patients' attitudes and experiences of online access to their electronic medical records: A qualitative study.

PubMed

Rexhepi, Hanife; Åhlfeldt, Rose-Mharie; Cajander, Åsa; Huvila, Isto

2018-06-01

Patients' access to their online medical records serves as one of the cornerstones in the efforts to increase patient engagement and improve healthcare outcomes. The aim of this article is to provide in-depth understanding of cancer patients' attitudes and experiences of online medical records, as well as an increased understanding of the complexities of developing and launching e-Health services. The study result confirms that online access can help patients prepare for doctor visits and to understand their medical issues. In contrast to the fears of many physicians, the study shows that online access to medical records did not generate substantial anxiety, concerns or increased phone calls to the hospital.

Medical innovation versus stem cell tourism.

PubMed

Lindvall, Olle; Hyun, Insoo

2009-06-26

Stem cell tourism is criticized on grounds of consumer fraud, blatant lack of scientific justification, and patient safety. However, the issues are complex because they invoke questions concerning the limits of acceptable medical innovation and medical travel. Here we discuss these issues and articulate conditions under which "unproven" therapies may be offered to patients outside of regular clinical trials.

A cornerstone of healthy aging: do we need to rethink the concept of adherence in the elderly?

PubMed

Giardini, Anna; Maffoni, Marina; Kardas, Przemyslaw; Costa, Elisio

2018-01-01

Worldwide, the population is aging and this trend will increase in the future due to medical, technological and scientific advancements. To take care of the elderly is highly demanding and challenging for the health care system due to their frequent condition of chronicity, multimorbidity and the consequent complex management of polypharmacy. Nonadherence to medications and to medical plans is a well-recognized public health problem and a very urgent issue in this population. For this reason, some considerations to identify a new shared approach to integrated care of older people are described. The concept of adherence should be considered as a complex and continuous process where family, caregivers and patients' beliefs come into play. Moreover, a new culture of adherence should contemplate the complexity of multimorbidity, as well as the necessity to renegotiate the medication regimen on the basis of each patient's needs.

Use of QR and EAN-13 codes by older patients taking multiple medications for a safer use of medication.

PubMed

Mira, José Joaquín; Guilabert, Mercedes; Carrillo, Irene; Fernández, César; Vicente, Ma Asunción; Orozco-Beltrán, Domingo; Gil-Guillen, Vicente F

2015-06-01

Older persons following a prolonged complex drug regimen often make mistakes when taking their medication. Currently, the widespread use of tablets and smartphones has encouraged the development of applications to support self-management of medication. The aim of this study was to design, develop and assess an app that transforms medication-associated ean-13 (barcodes) and Quick Response codes (QR) into verbal instructions, to enable safer use of medication by the elderly patients taking multiple medications. Meetings were held in which participated a total of 61 patients. The results showed that patients appreciated the application and found it useful for safer use of medicines. The study results support the use of such technology to increase patient safety taking multiple medications safety. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

The Patient Protection and Affordable Care Act: implications for pediatric pharmacy practice.

PubMed

Vallejos, Ximena; Benavides, Sandra

2013-01-01

The impact of the Patient Protection and Affordable Care Act on the pediatric health care landscape includes expanded health insurance coverage and health care delivery improvements by increasing implementation of patient-centered medical homes and accountable care organizations. These offer opportunities for pharmacists to assume responsibility for the medication-related needs of pediatric patients through pharmacotherapy selection, medication therapy management performance, and medication reconciliation at each transition of care. Medically complex children with at least 2 chronic disease states may be the target population. Studies demonstrating the positive outcomes and cost-effectiveness of pharmacists in pediatric ambulatory care settings are needed.

Medication adherence and persistence in type 2 diabetes mellitus: perspectives of patients, physicians and pharmacists on the Spanish health care system.

PubMed

Labrador Barba, Elena; Rodríguez de Miguel, Marta; Hernández-Mijares, Antonio; Alonso-Moreno, Francisco Javier; Orera Peña, Maria Luisa; Aceituno, Susana; Faus Dader, María José

2017-01-01

A good relationship between diabetes patients and their health care team is crucial to ensure patients' medication adherence and self-management. To this end, we aimed to identify and compare the views of type 2 diabetes mellitus (T2DM) patients, physicians and pharmacists concerning the factors and strategies that may be associated with, or could improve, medication adherence and persistence. An observational, cross-sectional study was conducted using an electronic self-administered questionnaire comprising 11 questions (5-point Likert scale) concerning factors and strategies related to medication adherence. The survey was designed for T2DM patients and Spanish National Health System professionals. A total of 963 T2DM patients, 998 physicians and 419 pharmacists participated in the study. Overall, a lower proportion of pharmacists considered the proposed factors associated with medication adherence important as compared to patients and physicians. It should be noted that a higher percentage of physicians in comparison to pharmacists perceived that "complexity of medication" (97% vs 76.6%, respectively) and "adverse events" (97.5% vs 72.2%, respectively) were important medication-related factors affecting adherence. In addition, both patients (80.8%) and physicians (80.8%) agreed on the importance of "cost and co-payment" for adherence, whereas only 48.6% of pharmacists considered this factor important. It is also noteworthy that nearly half of patients (43%) agreed that "to adjust medication to activities of daily living" was the best strategy to reduce therapeutic complexity, whereas physicians believed that "reducing the frequency of administration" (47.9%) followed by "reducing the number of tablets" (28.5%) was the most effective strategy to improve patients' adherence. Our results highlight the need for pharmacists to build a stronger relationship with physicians in order to improve patients monitoring and adherence rates. Additionally, these findings may help to incorporate greater patient-centeredness when developing management strategies, focusing on adjusting medication regimens to patients' daily lives.

Content standards for medical image metadata

NASA Astrophysics Data System (ADS)

d'Ornellas, Marcos C.; da Rocha, Rafael P.

2003-12-01

Medical images are at the heart of the healthcare diagnostic procedures. They have provided not only a noninvasive mean to view anatomical cross-sections of internal organs but also a mean for physicians to evaluate the patient"s diagnosis and monitor the effects of the treatment. For a Medical Center, the emphasis may shift from the generation of image to post processing and data management since the medical staff may generate even more processed images and other data from the original image after various analyses and post processing. A medical image data repository for health care information system is becoming a critical need. This data repository would contain comprehensive patient records, including information such as clinical data and related diagnostic images, and post-processed images. Due to the large volume and complexity of the data as well as the diversified user access requirements, the implementation of the medical image archive system will be a complex and challenging task. This paper discusses content standards for medical image metadata. In addition it also focuses on the image metadata content evaluation and metadata quality management.

Cardiac transplantation. Organ procurement to patient discharge.

PubMed

Rudolphi, D M; Nagy, K M; Verne, D J

1987-01-01

The care of the cardiac transplant patient is complex, yet rewarding. During the hospital stay, the patients, families, and nurses develop close-knit relationships that last after discharge. The cardiac transplant patients at Hershey Medical Center have formed a support group. To promote organ donation, they wear T-shirts, hats, and coats with the logo, "I got my heart at HMC," (Hershey Medical Center). This not only increases awareness of the need for organ donation, but also gives Hershey Medical Center recognition for its cardiac transplantation program.

The prescription of medical cannabis by a transitional pain service to wean a patient with complex pain from opioid use following liver transplantation: a case report.

PubMed

Meng, Howard; Hanlon, John G; Katznelson, Rita; Ghanekar, Anand; McGilvray, Ian; Clarke, Hance

2016-03-01

The purpose of this case report is to describe a patient with a preoperative complex pain syndrome who underwent liver transplantation and was able to reduce his opioid consumption significantly following the initiation of treatment with medical cannabis. A 57-yr-old male with a history of hepatitis C cirrhosis underwent liver transplantation. Preoperatively, he was taking hydromorphone 2-8 mg⋅day(-1) for chronic abdominal pain. Postoperatively, he was given intravenous patient-controlled analgesia through which he received hydromorphone 30 mg⋅day(-1). Our multidisciplinary Transitional Pain Service was involved with managing his moderate to severe acute postsurgical pain in hospital and continued with weaning him from opioid medications after discharge. It was difficult to wean the patient from opioids, and he was subsequently given medical cannabis at six weeks postoperatively with remarkable effect. By the fifth postoperative month, his use of opioids had tapered to 6 mg⋅day(-1) of hydromorphone, and his functional status was excellent on this regimen. Reductions in opioid consumption were achieved with the administration of medical cannabis in a patient with acute postoperative pain superimposed on a chronic pain syndrome and receiving high doses of opioids. Concurrent benefits of initiating medical cannabis may include improvements in pain profile and functional status along with reductions in opioid-related side effects. This highlights the potential for medical cannabis as an adjunct medication for weaning patients from opioid use.

Cross-cultural Adaptation and Validation of the Medication Regimen Complexity Index Adapted to Spanish.

PubMed

Saez de la Fuente, Javier; Such Diaz, Ana; Cañamares-Orbis, Irene; Ramila, Estela; Izquierdo-Garcia, Elsa; Esteban, Concepcion; Escobar-Rodríguez, Ismael

2016-11-01

The most widely used validated instrument to assess the complexity of medication regimens is the Medication Regimen Complexity Index (MRCI). This study aimed to translate, adapt, and validate a reliable version of the MRCI adapted to Spanish (MRCI-E). The cross-cultural adaptation process consisted of an independent translation by 3 clinical pharmacists and a backtranslation by 2 native English speakers. A reliability analysis was conducted on 20 elderly randomly selected patients. Two clinical pharmacists calculated the MRCI-E from discharge treatments and 2 months later. For the validity analysis, the sample was augmented to 60 patients. Convergent validity was assessed by analyzing the correlation between the number of medications; discriminant validity was stratified by gender; and predictive validity was determined by analyzing the ability to predict readmission and mortality at 3 and 6 months. The MRCI-E retained the original structure of 3 sections. The reliability analysis demonstrated an excellent internal consistency (Cronbach's α=0.83), and the intraclass correlation coefficient exceeded 0.9 in all cases. The correlation coefficient with the number of medications was 0.883 ( P<0.001). No significant differences were found when stratified by gender (3.6; 95%CI=-2.9 to 10.2; P=0.27). Patients who were readmitted at 3 months had a higher MRCI-E score (10.7; 95%CI=4.4 to 17.2; P=0.001). The differences remained significant in patients readmitted at 6 months, but differences in mortality were not detected. The MRCI-E retains the reliability and validity of the original index and provides a suitable tool to assess the complexity of medication regimens in Spanish.

Self-reported goals of older patients with type 2 diabetes mellitus.

PubMed

Huang, Elbert S; Gorawara-Bhat, Rita; Chin, Marshall H

2005-02-01

New diabetes mellitus guidelines from the American Geriatrics Society promote the individualization of treatment goals and plans for patients aged 65 and older. Communicating with older patients about such complex medical decisions presents new challenges for providers. The self-reported healthcare goals, factors influencing these goals, and self-care practices of older patients with diabetes mellitus were explored. Exploratory study involving semistructured interviews. Four clinics of a midwestern, urban academic medical center. Patients aged 65 and older with type II diabetes mellitus (N=28). Semistructured, one-on-one interviews were conducted. Interviews were audiotaped, transcribed, and evaluated for recurring themes using a grounded theory approach. The majority of patients expressed their healthcare goals in a social and functional language, in contrast to the biomedical language of risk factor control and complication prevention, even when specifically asked about goals for diabetes mellitus care. Patient's predominant healthcare goals centered on maintaining their independence and their activities of daily living (71%). Medical experiences of friends and family (50%), social comparison with peers (7%), and medical professionals (43%) shaped patients' goals. Self-reported medication adherence and glucose monitoring was high, but more than one-quarter of patients failed to adhere to any dietary recommendations, and one-third failed to adhere to their exercise regimens. As diabetes mellitus care recommendations for older patients grow more complex, providers could enhance their communication about such medical decisions by exploring patients' specific circumstances and reframing diabetes mellitus treatment goals in patients' own language. These may be crucial steps to developing successful individualized care plans.

Barriers to and facilitators of HIV-positive patients' adherence to antiretroviral treatment regimens.

PubMed

Roberts, K J

2000-03-01

HIV-positive patients must strictly adhere to antiretroviral regimens for the medications to work properly. Little, however, is known about the obstacles that patients face in adhering to the regimens or what, if anything, helps patients to adhere. The goals of the project were to describe, from HIV-positive patients' own perspectives, the barriers they face in adhering to antiretroviral regimens and the strategies they use to maximize their adherence. Five main barriers (forgetfulness, social/physical environment, complexity of the regimens, medication side effects, and inadequate patient knowledge) to adherence and six main facilitators (mechanical devices, "making a commitment," "routinizing," health beliefs, social support, and professional support) emerged from the data. Patients may overcome some of these barriers by receiving better health education about the need for adherence, professional and lay support for their efforts, and mechanical devices such as alarm clocks and medi-sets. Other barriers, however, such as the complexity of the medications, highlight the need for simplified antiretroviral regimens.

A feasibility study of a theory-based intervention to improve appropriate polypharmacy for older people in primary care.

PubMed

Cadogan, Cathal A; Ryan, Cristín; Gormley, Gerard J; Francis, Jill J; Passmore, Peter; Kerse, Ngaire; Hughes, Carmel M

2018-01-01

A general practitioner (GP)-targeted intervention aimed at improving the prescribing of appropriate polypharmacy for older people was previously developed using a systematic, theory-based approach based on the UK Medical Research Council's complex intervention framework. The primary intervention component comprised a video demonstration of a GP prescribing appropriate polypharmacy during a consultation with an older patient. The video was delivered to GPs online and included feedback emphasising the positive outcomes of performing the behaviour. As a complementary intervention component, patients were invited to scheduled medication review consultations with GPs. This study aimed to test the feasibility of the intervention and study procedures (recruitment, data collection). GPs from two general practices were given access to the video, and reception staff scheduled consultations with older patients receiving polypharmacy (≥4 medicines). Primary feasibility study outcomes were the usability and acceptability of the intervention to GPs. Feedback was collected from GP and patient participants using structured questionnaires. Clinical data were also extracted from recruited patients' medical records (baseline and 1 month post-consultation). The feasibility of applying validated assessment of prescribing appropriateness (STOPP/START criteria, Medication Appropriateness Index) and medication regimen complexity (Medication Regimen Complexity Index) to these data was investigated. Data analysis was descriptive, providing an overview of participants' feedback and clinical assessment findings. Four GPs and ten patients were recruited across two practices. The intervention was considered usable and acceptable by GPs. Some reservations were expressed by GPs as to whether the video truly reflected resource and time pressures encountered in the general practice working environment. Patient feedback on the scheduled consultations was positive. Patients welcomed the opportunity to have their medications reviewed. Due to the short time to follow-up and a lack of detailed clinical information in patient records, it was not feasible to detect any prescribing changes or to apply the assessment tools to patients' clinical data. The findings will help to further refine the intervention and study procedures (including time to follow-up) which will be tested in a randomised pilot study that will inform the design of a definitive trial to evaluate the intervention's effectiveness. ISRCTN18176245.

Aligning Medication Reconciliation and Secure Messaging: Qualitative Study of Primary Care Providers’ Perspectives

PubMed Central

Clark, Justice; Marcello, Thomas B; Paquin, Allison M; Stewart, Max; Archambeault, Cliona; Simon, Steven R

2013-01-01

Background Virtual (non-face-to-face) medication reconciliation strategies may reduce adverse drug events (ADEs) among vulnerable ambulatory patients. Understanding provider perspectives on the use of technology for medication reconciliation can inform the design of patient-centered solutions to improve ambulatory medication safety. Objective The aim of the study was to describe primary care providers’ experiences of ambulatory medication reconciliation and secure messaging (secure email between patients and providers), and to elicit perceptions of a virtual medication reconciliation system using secure messaging (SM). Methods This was a qualitative study using semi-structured interviews. From January 2012 to May 2012, we conducted structured observations of primary care clinical activities and interviewed 15 primary care providers within a Veterans Affairs Healthcare System in Boston, Massachusetts (USA). We carried out content analysis informed by the grounded theory. Results Of the 15 participating providers, 12 were female and 11 saw 10 or fewer patients in a typical workday. Experiences and perceptions elicited from providers during in-depth interviews were organized into 12 overarching themes: 4 themes for experiences with medication reconciliation, 3 themes for perceptions on how to improve ambulatory medication reconciliation, and 5 themes for experiences with SM. Providers generally recognized medication reconciliation as a valuable component of primary care delivery and all agreed that medication reconciliation following hospital discharge is a key priority. Most providers favored delegating the responsibility for medication reconciliation to another member of the staff, such as a nurse or a pharmacist. The 4 themes related to ambulatory medication reconciliation were (1) the approach to complex patients, (2) the effectiveness of medication reconciliation in preventing ADEs, (3) challenges to completing medication reconciliation, and (4) medication reconciliation during transitions of care. Specifically, providers emphasized the importance of medication reconciliation at the post-hospital visit. Providers indicated that assistance from a caregiver (eg, a family member) for medication reconciliation was helpful for complex or elderly patients and that patients’ social or cognitive factors often made medication reconciliation challenging. Regarding providers’ use of SM, about half reported using SM frequently, but all felt that it improved their clinical workflow and nearly all providers were enthusiastic about a virtual medication reconciliation system, such as one using SM. All providers thought that such a system could reduce ADEs. Conclusions Although providers recognize the importance and value of ambulatory medication reconciliation, various factors make it difficult to execute this task effectively, particularly among complex or elderly patients and patients with complicated social circumstances. Many providers favor enlisting the support of pharmacists or nurses to perform medication reconciliation in the outpatient setting. In general, providers are enthusiastic about the prospect of using secure messaging for medication reconciliation, particularly during transitions of care, and believe a system of virtual medication reconciliation could reduce ADEs. PMID:24297865

Top 10 things palliative care clinicians wished everyone knew about palliative care.

PubMed

Strand, Jacob J; Kamdar, Mihir M; Carey, Elise C

2013-08-01

With a focus on improving quality of life for patients, palliative care is a rapidly growing medical subspecialty focusing on the care of patients with serious illness. Basic symptom management, discussions of prognostic understanding, and eliciting treatment goals are essential pieces in the practice of nearly all physicians. Nonetheless, many complex patients with a serious, life-threatening illness benefit from consultation with palliative care specialists, who are trained and experienced in complex symptom management and challenging communication interactions, including medical decision making and aligning goals of care. This article discusses the changing role of modern palliative care, addresses common misconceptions, and presents an argument for early integration of palliative care in the treatment of patients dealing with serious illness. Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Patients' Perspective on the Value of Medication Management Appointments.

PubMed

Cruz, Mario; Cruz, Robyn Flaum; Pincus, Harold Alan

2015-05-20

There is ongoing concern that psychiatric medication management appointments add little value to care. The present study attempted to address this concern by capturing depressed patients' views and opinions about the value of psychiatric medication management appointments. Seventy-eight semi-structured interviews were performed with white and African American depressed patients post medication management appointments. These interviews tapped patients' views and opinions about the value of attending medication management appointments. An iterative thematic analysis was performed. Patients reported greater appointment value when appointments included obtaining medications, discussing the need for medication changes or dose adjustments, and discussing the impact of medications on their illness. Additionally, greater appointment value was perceived by patients when there were non-medical conversations about life issues, immediate outcomes from the appointment such as motivation to continue in care, and specific qualities of providers that were appealing to patients. Patients' perceived value of psychiatric medication management appointments is complex. Though important patient outcomes are obtaining medicine and perceiving improvement in their mental health, there are other valued appointment and provider factors. Some of these other valued factors embedded within medication management appointments could have therapeutic properties. These findings have implications for future clinical research and service delivery.

Distributed Computer Networks in Support of Complex Group Practices

PubMed Central

Wess, Bernard P.

1978-01-01

The economics of medical computer networks are presented in context with the patient care and administrative goals of medical networks. Design alternatives and network topologies are discussed with an emphasis on medical network design requirements in distributed data base design, telecommunications, satellite systems, and software engineering. The success of the medical computer networking technology is predicated on the ability of medical and data processing professionals to design comprehensive, efficient, and virtually impenetrable security systems to protect data bases, network access and services, and patient confidentiality.

Helping Older Adults Improve Their Medication Experience (HOME) by Addressing Medication Regimen Complexity in Home Healthcare.

PubMed

Sheehan, Orla C; Kharrazi, Hadi; Carl, Kimberly J; Leff, Bruce; Wolff, Jennifer L; Roth, David L; Gabbard, Jennifer; Boyd, Cynthia M

In skilled home healthcare (SHHC), communication between nurses and physicians is often inadequate for medication reconciliation and needed changes to the medication regimens are rarely made. Fragmentation of electronic health record (EHR) systems, transitions of care, lack of physician-nurse in-person contact, and poor understanding of medications by patients and their families put patients at risk for serious adverse outcomes. The aim of this study was to develop and test the HOME tool, an informatics tool to improve communication about medication regimens, share the insights of home care nurses with physicians, and highlight to physicians and nurses the complexity of medication schedules. We used human computer interaction design and evaluation principles, automated extraction from standardized forms, and modification of existing EHR fields to highlight key medication-related insights that had arisen during the SHHC visit. Separate versions of the tool were developed for physicians/nurses and patients/caregivers. A pilot of the tool was conducted using 20 SHHC encounters. Home care nurses and physicians found the tool useful for communication. Home care nurses were able to implement the HOME tool into their clinical workflow and reported improved communication with physicians about medications. This simple and largely automated tool improves understanding and communication around medications in SHHC.

Developing a Systematic Architecture Approach for Designing an Enhanced Electronic Medical Record (EEMR) System

ERIC Educational Resources Information Center

Aldukheil, Maher A.

2013-01-01

The Healthcare industry is characterized by its complexity in delivering care to the patients. Accordingly, healthcare organizations adopt and implement Information Technology (IT) solutions to manage complexity, improve quality of care, and transform to a fully integrated and digitized environment. Electronic Medical Records (EMR), which is…

Resident and Staff Satisfaction of Pediatric Graduate Medical Education Training on Transition to Adult Care of Medically Complex Patients.

PubMed

Weeks, Matthew; Cole, Brandon; Flake, Eric; Roy, Daniel

2018-04-11

This study aims to describe the quantity and satisfaction current residents and experienced pediatricians have with graduate medical education on transitioning medically complex patients to adult care. There is an increasing need for transitioning medically complex adolescents to adult care. Over 90% now live into adulthood and require transition to adult healthcare providers. The 2010 National Survey of Children with Special Health Care Needs found that only 40% of youth 12-17 yr receive the necessary services to appropriately transition to adult care. Prospective, descriptive, anonymous, web-based survey of pediatric residents and staff pediatricians at Army pediatric residency training programs was sent in March 2017. Questions focused on assessing knowledge of transition of care, satisfaction with transition training, and amount of education on transition received during graduate medical education training. Of the 145 responders (310 potential responders, 47% response rate), transition was deemed important with a score of 4.3 out of 5. The comfort level with transition was rated 2.6/5 with only 4.2% of participants receiving formal education during residency. The most commonly perceived barriers to implementing a curriculum were time constraints and available resources. Of the five knowledge assessment questions, three had a correct response rate of less than 1/3. The findings show the disparity between the presence of and perceived need for a formal curriculum on transitioning complex pediatric patients to adult care. This study also highlighted the knowledge gap of the transition process for novice and experienced pediatricians alike.

Automation of a high risk medication regime algorithm in a home health care population.

PubMed

Olson, Catherine H; Dierich, Mary; Westra, Bonnie L

2014-10-01

Create an automated algorithm for predicting elderly patients' medication-related risks for readmission and validate it by comparing results with a manual analysis of the same patient population. Outcome and Assessment Information Set (OASIS) and medication data were reused from a previous, manual study of 911 patients from 15 Medicare-certified home health care agencies. The medication data was converted into standardized drug codes using APIs managed by the National Library of Medicine (NLM), and then integrated in an automated algorithm that calculates patients' high risk medication regime scores (HRMRs). A comparison of the results between algorithm and manual process was conducted to determine how frequently the HRMR scores were derived which are predictive of readmission. HRMR scores are composed of polypharmacy (number of drugs), Potentially Inappropriate Medications (PIM) (drugs risky to the elderly), and Medication Regimen Complexity Index (MRCI) (complex dose forms, instructions or administration). The algorithm produced polypharmacy, PIM, and MRCI scores that matched with 99%, 87% and 99% of the scores, respectively, from the manual analysis. Imperfect match rates resulted from discrepancies in how drugs were classified and coded by the manual analysis vs. the automated algorithm. HRMR rules lack clarity, resulting in clinical judgments for manual coding that were difficult to replicate in the automated analysis. The high comparison rates for the three measures suggest that an automated clinical tool could use patients' medication records to predict their risks of avoidable readmissions. Copyright © 2014 Elsevier Inc. All rights reserved.

Beliefs related to adherence to oral antidiabetic treatment according to the Theory of Planned Behavior1

PubMed Central

Jannuzzi, Fernanda Freire; Rodrigues, Roberta Cunha Matheus; Cornélio, Marilia Estevam; São-João, Thaís Moreira; Gallani, Maria Cecília Bueno Jayme

2014-01-01

OBJECTIVE: to identify salient behavioral, normative, control and self-efficacy beliefs related to the behavior of adherence to oral antidiabetic agents, using the Theory of Planned Behavior. METHOD: cross-sectional, exploratory study with 17 diabetic patients in chronic use of oral antidiabetic medication and in outpatient follow-up. Individual interviews were recorded, transcribed and content-analyzed using pre-established categories. RESULTS: behavioral beliefs concerning advantages and disadvantages of adhering to medication emerged, such as the possibility of avoiding complications from diabetes, preventing or delaying the use of insulin, and a perception of side effects. The children of patients and physicians are seen as important social references who influence medication adherence. The factors that facilitate adherence include access to free-of-cost medication and taking medications associated with temporal markers. On the other hand, a complex therapeutic regimen was considered a factor that hinders adherence. Understanding how to use medication and forgetfulness impact the perception of patients regarding their ability to adhere to oral antidiabetic agents. CONCLUSION: medication adherence is a complex behavior permeated by behavioral, normative, control and self-efficacy beliefs that should be taken into account when assessing determinants of behavior. PMID:25296135

Beliefs related to adherence to oral antidiabetic treatment according to the Theory of Planned Behavior.

PubMed

Jannuzzi, Fernanda Freire; Rodrigues, Roberta Cunha Matheus; Cornélio, Marilia Estevam; São-João, Thaís Moreira; Gallani, Maria Cecília Bueno Jayme

2014-01-01

to identify salient behavioral, normative, control and self-efficacy beliefs related to the behavior of adherence to oral antidiabetic agents, using the Theory of Planned Behavior. cross-sectional, exploratory study with 17 diabetic patients in chronic use of oral antidiabetic medication and in outpatient follow-up. Individual interviews were recorded, transcribed and content-analyzed using pre-established categories. behavioral beliefs concerning advantages and disadvantages of adhering to medication emerged, such as the possibility of avoiding complications from diabetes, preventing or delaying the use of insulin, and a perception of side effects. The children of patients and physicians are seen as important social references who influence medication adherence. The factors that facilitate adherence include access to free-of-cost medication and taking medications associated with temporal markers. On the other hand, a complex therapeutic regimen was considered a factor that hinders adherence. Understanding how to use medication and forgetfulness impact the perception of patients regarding their ability to adhere to oral antidiabetic agents. medication adherence is a complex behavior permeated by behavioral, normative, control and self-efficacy beliefs that should be taken into account when assessing determinants of behavior.

Nonadherence to Medication Therapy in Haemodialysis Patients: A Systematic Review

PubMed Central

Ghimire, Saurav; Castelino, Ronald L.; Lioufas, Nicole M.; Peterson, Gregory M.; Zaidi, Syed Tabish R.

2015-01-01

Background End-stage kidney disease (ESKD) patients are often prescribed multiple medications. Together with a demanding weekly schedule of dialysis sessions, increased number of medicines and associated regimen complexity pre-dispose them at high risk of medication nonadherence. This review summarizes existing literature on nonadherence and identifies factors associated with nonadherence to medication therapy in patients undergoing haemodialysis. Methods A comprehensive search of PubMed, Embase, CINAHL, PsycInfo, and Cochrane Database of Systematic Reviews covering the period from 1970 through November 2014 was performed following a predefined inclusion and exclusion criteria. Reference lists from relevant materials were reviewed. Data on study characteristics, measures of nonadherence, prevalence rates and factors associated with nonadherence were collected. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was followed in conducting this systematic review. Results Of 920 relevant publications, 44 were included. The prevalence of medication nonadherence varied from 12.5% to 98.6%, with widespread heterogeneity in measures and definitions employed. Most common patient-related factors significantly associated with nonadherence were younger age, non-Caucasian ethnicity, illness interfering family life, being a smoker, and living single and being divorced or widowed. Similarly, disease-related factors include longevity of haemodialysis, recurrent hospitalization, depressive symptoms and having concomitant illness like diabetes and hypertension. Medication-related factors such as daily tablet count, total pill burden, number of phosphate binders prescribed and complexity of medication regimen were also associated with poor adherence. Conclusions A number of patient-, disease-, and medication-related factors are associated with medication nonadherence in haemodialysis patients. Clinicians should be aware of such factors so that adherence to medications can be optimised in haemodialysis patients. Future research should be directed towards well-designed prospective longitudinal studies developing standard definitions and validating available measurement tools, while focusing on the role of additional factors such as psychosocial and behavioural factors in predicting nonadherence to medications. PMID:26636968

Nonadherence to Medication Therapy in Haemodialysis Patients: A Systematic Review.

PubMed

Ghimire, Saurav; Castelino, Ronald L; Lioufas, Nicole M; Peterson, Gregory M; Zaidi, Syed Tabish R

2015-01-01

End-stage kidney disease (ESKD) patients are often prescribed multiple medications. Together with a demanding weekly schedule of dialysis sessions, increased number of medicines and associated regimen complexity pre-dispose them at high risk of medication nonadherence. This review summarizes existing literature on nonadherence and identifies factors associated with nonadherence to medication therapy in patients undergoing haemodialysis. A comprehensive search of PubMed, Embase, CINAHL, PsycInfo, and Cochrane Database of Systematic Reviews covering the period from 1970 through November 2014 was performed following a predefined inclusion and exclusion criteria. Reference lists from relevant materials were reviewed. Data on study characteristics, measures of nonadherence, prevalence rates and factors associated with nonadherence were collected. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was followed in conducting this systematic review. Of 920 relevant publications, 44 were included. The prevalence of medication nonadherence varied from 12.5% to 98.6%, with widespread heterogeneity in measures and definitions employed. Most common patient-related factors significantly associated with nonadherence were younger age, non-Caucasian ethnicity, illness interfering family life, being a smoker, and living single and being divorced or widowed. Similarly, disease-related factors include longevity of haemodialysis, recurrent hospitalization, depressive symptoms and having concomitant illness like diabetes and hypertension. Medication-related factors such as daily tablet count, total pill burden, number of phosphate binders prescribed and complexity of medication regimen were also associated with poor adherence. A number of patient-, disease-, and medication-related factors are associated with medication nonadherence in haemodialysis patients. Clinicians should be aware of such factors so that adherence to medications can be optimised in haemodialysis patients. Future research should be directed towards well-designed prospective longitudinal studies developing standard definitions and validating available measurement tools, while focusing on the role of additional factors such as psychosocial and behavioural factors in predicting nonadherence to medications.

Towards a pedagogy for patient and public involvement in medical education.

PubMed

Regan de Bere, Sam; Nunn, Suzanne

2016-01-01

This paper presents a critique of current knowledge on the engagement of patients and the public, referred to here as patient and public involvement (PPI), and calls for the development of robust and theoretically informed strategies across the continuum of medical education. The study draws on a range of relevant literatures and presents PPI as a response process in relation to patient-centred learning agendas. Through reference to original research it discusses three key priorities for medical educators developing early PPI pedagogies, including: (i) the integration of evidence on PPI relevant to medical education, via a unifying corpus of literature; (ii) conceptual clarity through shared definitions of PPI in medical education, and (iii) an academically rigorous approach to managing complexity in the evaluation of PPI initiatives. As a response to these challenges, the authors demonstrate how activity modelling may be used as an analytical heuristic to provide an understanding of a number of PPI systems that may interact within complex and dynamic educational contexts. The authors highlight the need for a range of patient voices to be evident within such work, from its generation through to dissemination, in order that patients and the public are partners and not merely objects of this endeavour. To this end, this paper has been discussed with and reviewed by our own patient and public research partners throughout the writing process. © 2015 John Wiley & Sons Ltd.

Electronic Medical Business Operations System

DOE Office of Scientific and Technical Information (OSTI.GOV)

Cannon, D. T.; Metcalf, J. R.; North, M. P.

Electronic Management of medical records has taken a back seat both in private industry and in the government. Record volumes continue to rise every day and management of these paper records is inefficient and very expensive. In 2005, the White House announced support for the development of electronic medical records across the federal government. In 2006, the DOE issued 10 CFR 851 requiring all medical records be electronically available by 2015. The Y-12 National Security Complex is currently investing funds to develop a comprehensive EMR to incorporate the requirements of an occupational health facility which are common across the Nuclearmore » Weapons Complex (NWC). Scheduling, workflow, and data capture from medical surveillance, certification, and qualification examinations are core pieces of the system. The Electronic Medical Business Operations System (EMBOS) will provide a comprehensive health tool solution to 10 CFR 851 for Y-12 and can be leveraged to the Nuclear Weapon Complex (NWC); all site in the NWC must meet the requirements of 10 CFR 851 which states that all medical records must be electronically available by 2015. There is also potential to leverage EMBOS to the private4 sector. EMBOS is being developed and deployed in phases. When fully deployed the EMBOS will be a state-of-the-art web-enabled integrated electronic solution providing a complete electronic medical record (EMR). EMBOS has been deployed and provides a dynamic electronic medical history and surveillance program (e.g., Asbestos, Hearing Conservation, and Respirator Wearer) questionnaire. Table 1 below lists EMBOS capabilities and data to be tracked. Data to be tracked: Patient Demographics – Current/Historical; Physical Examination Data; Employee Medical Health History; Medical Surveillance Programs; Patient and Provider Schedules; Medical Qualification/Certifications; Laboratory Data; Standardized Abnormal Lab Notifications; Prescription Medication Tracking and Dispensing; Allergies; Non-Occupational Illness and Injury Visits; Occupational Recommendations/Restrictions; Diagnosis/Vital Signs/Blood Pressures; Immunizations; Return to Work Visits Capabilities: Targeted Health Assessments; Patient Input Capabilities for Questionnaires; Medical Health History; Surveillance Programs; Human Reliability Program; Scheduling; Automated Patient Check-in/Check-out; Provider & Patient Workflow; Laboratory Interface & Device Integration; Human Reliability Program Processing; Interoperability with SAP, IH, IS, RADCON; Coding: ICED-9/10; Desktop Integration; Interface/Storage of Digital X-Rays (PACS)« less

Diversity, the Individual, and Proof of Efficacy: Complementary and Alternative Medicine in Medical Education

PubMed Central

Park, Constance M.

2002-01-01

Patients will always have access to a variety of possibly effective, but unproved, therapies directed at maintaining health or treating illness. And there will always be complex, potentially therapeutic regimens that cannot be adequately tested for financial, ethical, or methodological reasons. Furthermore, even after adequate study of a given regimen, there will always be the fundamental uncertainty of medical practice: the fact that epidemiological research produces probabilistic results that cannot predict with certainty the best treatment for the single unique patient before us. The exploration of complementary and alternative medicine topics in the medical school curriculum helps to elucidate the complex and uncertain nature of medical practice, sharpens skills for clinical decisionmaking, increases cultural sensitivity, and provides ideas for future research. PMID:12356593

Capturing the experiences of patients across multiple complex interventions: a meta-qualitative approach

PubMed Central

Webster, Fiona; Christian, Jennifer; Mansfield, Elizabeth; Bhattacharyya, Onil; Hawker, Gillian; Levinson, Wendy; Naglie, Gary; Pham, Thuy-Nga; Rose, Louise; Schull, Michael; Sinha, Samir; Stergiopoulos, Vicky; Upshur, Ross; Wilson, Lynn

2015-01-01

Objectives The perspectives, needs and preferences of individuals with complex health and social needs can be overlooked in the design of healthcare interventions. This study was designed to provide new insights on patient perspectives drawing from the qualitative evaluation of 5 complex healthcare interventions. Setting Patients and their caregivers were recruited from 5 interventions based in primary, hospital and community care in Ontario, Canada. Participants We included 62 interviews from 44 patients and 18 non-clinical caregivers. Intervention Our team analysed the transcripts from 5 distinct projects. This approach to qualitative meta-evaluation identifies common issues described by a diverse group of patients, therefore providing potential insights into systems issues. Outcome measures This study is a secondary analysis of qualitative data; therefore, no outcome measures were identified. Results We identified 5 broad themes that capture the patients’ experience and highlight issues that might not be adequately addressed in complex interventions. In our study, we found that: (1) the emergency department is the unavoidable point of care; (2) patients and caregivers are part of complex and variable family systems; (3) non-medical issues mediate patients’ experiences of health and healthcare delivery; (4) the unanticipated consequences of complex healthcare interventions are often the most valuable; and (5) patient experiences are shaped by the healthcare discourses on medically complex patients. Conclusions Our findings suggest that key assumptions about patients that inform intervention design need to be made explicit in order to build capacity to better understand and support patients with multiple chronic diseases. Across many health systems internationally, multiple models are being implemented simultaneously that may have shared features and target similar patients, and a qualitative meta-evaluation approach, thus offers an opportunity for cumulative learning at a system level in addition to informing intervention design and modification. PMID:26351182

Autism in Two Females with Duplications Involving Xp11.22-p11.23

ERIC Educational Resources Information Center

Edens, Anna C.; Lyons, Michael J.; Duron, Reyna M.; DuPont, Barbara R.; Holden, Kenton R.

2011-01-01

We present two phenotypically similar females with Xp duplication who have autism and epilepsy. Case 1 is a 14-year-old Honduran female with autism and medically refractory complex partial, secondarily generalized epilepsy. Case 2 is a 3-year-old Austrian female with autism and medically refractory complex partial epilepsy. Both patients also…

Genotypic and Phenotypic Correlations of Multidrug-Resistant Acinetobacter baumannii-A. calcoaceticus Complex Strains Isolated from Patients at the National Naval Medical Center

USDA-ARS?s Scientific Manuscript database

Acinetobacter baumannii-calcoaceticus complex (ABC) infections have complicated the care of U.S. combat casualties. In this study, 102 ABC isolates from wounded soldiers treated at National Naval Medical Center (NNMC) were characterized by phenotype and genotype to identify clones in this population...

Lifting the veil.

PubMed

Sorrel, Amy Lynn

2014-07-01

As governments and employers look for ways to curb growing health care costs, and as patients bear a higher share of their medical bills, policymakers in Texas and beyond increasingly target physicians in their efforts to unveil health care prices. They couch such "price transparency" as a way to help patients make more informed health care decisions. But Texas Medical Association's Board of Trustees member Gary W. Floyd, MD, of Fort Worth, cautions that for a complex health care payment system, coupled with individual patients' complex needs, coming up with a so-called "sticker price" is not as simple as it seems.

Self-Reported Goals of Older Patients with Type 2 Diabetes Mellitus

PubMed Central

Huang, Elbert S.; Gorawara-Bhat, Rita; Chin, Marshall H.

2008-01-01

OBJECTIVES New diabetes mellitus guidelines from the American Geriatrics Society promote the individualization of treatment goals and plans for patients aged 65 and older. Communicating with older patients about such complex medical decisions presents new challenges for providers. The self-reported healthcare goals, factors influencing these goals, and self-care practices of older patients with diabetes mellitus were explored. DESIGN Exploratory study involving semistructured interviews. SETTING Four clinics of a midwestern, urban academic medical center. PARTICIPANTS Patients aged 65 and older with type II diabetes mellitus (N = 28). MEASUREMENTS Semistructured, one-on-one interviews were conducted. Interviews were audiotaped, transcribed, and evaluated for recurring themes using a grounded theory approach. RESULTS The majority of patients expressed their health-care goals in a social and functional language, in contrast to the biomedical language of risk factor control and complication prevention, even when specifically asked about goals for diabetes mellitus care. Patient’s predominant healthcare goals centered on maintaining their independence and their activities of daily living (71%). Medical experiences of friends and family (50%), social comparison with peers (7%), and medical professionals (43%) shaped patients’ goals. Self-reported medication adherence and glucose monitoring was high, but more than one-quarter of patients failed to adhere to any dietary recommendations, and one-third failed to adhere to their exercise regimens. CONCLUSION As diabetes mellitus care recommendations for older patients grow more complex, providers could enhance their communication about such medical decisions by exploring patients’ specific circumstances and reframing diabetes mellitus treatment goals in patients’ own language. These may be crucial steps to developing successful individualized care plans PMID:15673357

When you can't have the cake and eat it too: a study of medical doctors' priorities in complex choice situations.

PubMed

Carlsen, Benedicte; Hole, Arne Risa; Kolstad, Julie Riise; Norheim, Ole Frithjof

2012-12-01

Available literature provides little insight into medical doctors' prescription choices when they are required to make complex trade-offs between different concerns such as treatment effect, costs, and patient preferences simultaneously. This study investigates this issue. It is based on a Discrete Choice Experiment (DCE) conducted with 571 Norwegian doctors, where the DCE captures preferences for medications described along five dimensions important for both clinical decision-making and prioritisation in the health sector. Although effectiveness is the most important determinant of choice in our study, doctors also put considerable weight on patients' preferences and on avoiding high total costs. The probability of choosing a particular medication increases when doctors have a positive experience with the medication. GPs value high clinical effectiveness less than hospital consultants do. They are also less concerned with patient preferences. For both groups of doctors it turns out that they are willing to make difficult trade-offs between attributes they are often assumed not to be willing to compromise on, like effectiveness or patient preferences, and cost measures - given that they have proper information about these attributes. Copyright © 2012 Elsevier Ltd. All rights reserved.

Applying principles from the game theory to acute stroke care: Learning from the prisoner's dilemma, stag-hunt, and other strategies.

PubMed

Saposnik, Gustavo; Johnston, S Claiborne

2016-04-01

Acute stroke care represents a challenge for decision makers. Decisions based on erroneous assessments may generate false expectations of patients and their family members, and potentially inappropriate medical advice. Game theory is the analysis of interactions between individuals to study how conflict and cooperation affect our decisions. We reviewed principles of game theory that could be applied to medical decisions under uncertainty. Medical decisions in acute stroke care are usually made under constrains: short period of time, with imperfect clinical information, limit understanding about patients and families' values and beliefs. Game theory brings some strategies to help us manage complex medical situations under uncertainty. For example, it offers a different perspective by encouraging the consideration of different alternatives through the understanding of patients' preferences and the careful evaluation of cognitive distortions when applying 'real-world' data. The stag-hunt game teaches us the importance of trust to strength cooperation for a successful patient-physician interaction that is beyond a good or poor clinical outcome. The application of game theory to stroke care may improve our understanding of complex medical situations and help clinicians make practical decisions under uncertainty. © 2016 World Stroke Organization.

Medication adherence in glaucoma: approaches for optimizing patient compliance.

PubMed

Tsai, James C

2006-04-01

To summarize recent literature regarding medication adherence with a focus on the complexities inherent in glaucoma management. Adherence to medications can be enhanced by undertaking the following strategies: enhanced patient education; improved dosing schedules; increased accessibility to healthcare (including longer hours, evening hours, and shorter wait times), and improved provider-patient relationships (e.g. increased trust). Patients may be less likely to forgo medication use due to cost pressures if the physician trust level is high. Recent studies suggest a role for baseline screening for adherence predictors and focused interventions in addressing modifiable risk factors for poor adherence (such as depression, stress, and lower education). Many factors are associated with the lack of medication adherence in patients. The solution is likely to be multi-dimensional and employ combination strategy (must be individualized for the patient). Educational interventions involving patients, family members, or both can be effective in improving adherence.

Artificial intelligence (AI) systems for interpreting complex medical datasets.

PubMed

Altman, R B

2017-05-01

Advances in machine intelligence have created powerful capabilities in algorithms that find hidden patterns in data, classify objects based on their measured characteristics, and associate similar patients/diseases/drugs based on common features. However, artificial intelligence (AI) applications in medical data have several technical challenges: complex and heterogeneous datasets, noisy medical datasets, and explaining their output to users. There are also social challenges related to intellectual property, data provenance, regulatory issues, economics, and liability. © 2017 ASCPT.

Perspectives on counseling patients about menopausal hormone therapy: strategies in a complex data environment.

PubMed

Parish, Sharon J; Nappi, Rossella E; Kingsberg, Sheryl

2018-03-05

This narrative review strives to give healthcare providers (HCPs) who care for menopausal women better tools and skills to initiate discussions with women about menopause and hormone therapy (HT), communicate complex concepts and data, and promote shared decision-making. We review relevant studies on HT, barriers to treatment of menopausal symptoms, and effective communication strategies. We also provide recommendations for communicating with patients about HT based on the medical literature and our own professional experience. Both patient and HCP-related barriers can prevent women from accessing treatment for bothersome symptoms of menopause. Many women and HCPs have a poor understanding of the complex, nuanced data regarding HT. The benefits and risks vary with patient age and time since menopause, duration of use, inclusion of a progestin, and patient medical history. Women may also have fears about potential side effects of HT and feel unable to make informed choices. Strategies for effective patient communication and shared decision-making include use of open-ended questions to elicit patient's concerns and preferences, reflecting back to the patient what the HCP heard, presenting evidence about benefits and risks in language the patient can understand, keeping risks in perspective (eg, provide absolute, and also relative risks) without minimizing them, and making conscious efforts to minimize potential bias. Necessary components for achieving high-quality, shared decisions about HT involve a combination of medical evidence, communication skills, and recognition of patient goals and concerns. Use of such strategies can enhance women's satisfaction with care.

[Concept analysis of medication adherence in patients with chronic disease].

PubMed

Huang, Jen-Ying; Chen, Hsing-Mei

2014-06-01

Pharmacotherapy plays an important role in the management of chronic diseases. However, many patients with chronic disease do not adhere to their medication regimen. This results in worsening symptoms and frequent re-hospitalizations. As a result, healthcare providers may view these patients as bad. Medication adherence is a complex concept. Analyzing this concept may assist nurses to improve patient-centered care. This paper uses Walker & Avant's method to conduct a concept analysis of medication adherence. Results show the defining attributes of medication adherence as: (1) knowing and agreeing to the medication; (2) communicating and negotiating the regimen; and (3) active, continuous involvement in and appraisal of the treatment effect. Identified antecedents of medication adherence included the patient having: (1) a prescribed medication regimen; (2) cognitive and action abilities in her / his role as a patient; and (3) level of preparation for medication treatment. Identified consequences of medication adherence include: (1) improving symptom control; (2) decreasing re-hospitalizations and mortality; (3) reducing medical care costs; (4) restoring self-esteem; and (5) diminishing depression. It is hoped that this concept analysis provides a reference for nurses to achieve a better understanding of medication adherence and further improve nursing practice.

Medical students' opportunities to participate and learn from activities at an internal medicine ward: an ethnographic study

PubMed Central

Hägg-Martinell, A; Hult, H; Henriksson, P; Kiessling, A

2017-01-01

Objectives To optimise medical students’ early clerkship is a complex task since it is conducted in a context primarily organised to take care of patients. Previous studies have explored medical students’ perceptions of facilitation and hindrance of learning. However, the opportunities for medical student to learn within the culture of acute medicine care have not been fully investigated. This study aimed to explore how medical students approach, interact and socialise in an acute internal medicine ward context, and how spaces for learning are created and used in such a culture. Design and setting Ethnographic observations were performed of medical students' interactions and learning during early clerkship at an acute internal medicine care ward. Field notes were taken, transcribed and analysed qualitatively. Data analysis was guided by Wenger's theory of communities of practice. Participants 21 medical students and 30 supervisors participated. Results Two themes were identified: Nervousness and curiosity—students acted nervously and stressed, especially when they could not answer questions. Over time curiosity could evolve. Unexplored opportunities to support students in developing competence to judge and approach more complex patient-related problems were identified. Invited and involved—students were exposed to a huge variation of opportunities to learn, and to interact and to be involved. Short placements seemed to disrupt the learning process. If and how students became involved also depended on supervisors' activities and students' initiatives. Conclusions This study shed light on how an acute internal medicine ward culture can facilitate medical students' possibilities to participate and learn. Medical students' learning situations were characterised by questions and answers rather than challenging dialogues related to the complexity of presented patient cases. Further, students experienced continuous transfers between learning situations where the potential to be involved differed in a wide variety of ways. PMID:28196948

Integration of remote blood glucose meter upload technology into a clinical pharmacist medication therapy management service.

PubMed

Schenk, Robert J; Schenk, Jenna

2011-01-01

A pharmacist-delivered, outpatient-focused medication therapy management (MTM) program is using a remote blood glucose (BG) meter upload device to provide better care and to improve outcomes for its patients with diabetes. Sharing uploaded BG meter data, presented in easily comprehensible graphs and charts, enables patients, caregivers, and the medical team to better understand how the patients' diabetes care is progressing. Pharmacists are becoming increasingly more active in helping to manage patients' complex medication regimens in an effort to help detect and avoid medication-related problems. Working together with patients and their physicians as part of an interdisciplinary health care team, pharmacists are helping to improve medication outcomes. This article focuses on two case studies highlighting the Diabetes Monitoring Program, one component of the Meridian Pharmacology Institute MTM service, and discusses the clinical application of a unique BG meter upload device. © 2010 Diabetes Technology Society.

Complexities of emergency communication: clinicians' perceptions of communication challenges in a trilingual emergency department.

PubMed

Pun, Jack Kh; Chan, Engle Angela; Murray, Kristen A; Slade, Diana; Matthiessen, Christian Mim

2017-11-01

To understand the challenges that clinicians face in communicating with patients and other clinicians within a Hong Kong trilingual emergency department. Effective communication has long been recognised as fundamental to the delivery of quality health care, especially in high-risk and time-constrained environments such as emergency departments. The issue of effective communication is particularly relevant in Hong Kong emergency departments, due to the high volume of patients and the linguistic complexity of this healthcare context. In Hong Kong, emergency department clinicians are native speakers of Chinese, but have received their medical training in English. The clinicians read and record virtually all of their medical documentation in English, yet they communicate verbally with patients in Cantonese and Mandarin. In addition, communication between clinicians occurs in spoken Cantonese, mixed with medical English. Thus, medical information is translated numerous times within one patient journey. This complex linguistic environment creates the potential for miscommunication. A mixed-methods design consisting of a quantitative survey with a sequential qualitative interview. Data were collected in a survey from a purposive sample of 58 clinicians and analysed through descriptive statistics. Eighteen of the clinicians were then invited to take part in semi-structured interviews, the data from which were then subjected to a manifest content analysis. Nearly half of the clinicians surveyed believed that medical information may be omitted or altered through repeated translation in a trilingual emergency department. Eighty-three per cent of clinicians stated that there are communication problems at triage. Over 40% said that they have difficulties in documenting medical information. Around 50% believed that long work hours reduced their ability to communicate effectively with patients. In addition, 34% admitted that they rarely or never listen to patients during a consultation. The findings reveal that the quality of communication in this Hong Kong emergency department is compromised by specific factors inherent in the linguistic complexity of Hong Kong emergency departments. These factors include the constant translation of medical information, inadequate documentation of medical information and significant professional and cultural pressures. Each of these issues increases the likelihood that healthcare communication will be difficult, incomplete or incorrect. This research provides empirical evidence for, and justifies the development of, an effective framework to enable clinicians to overcome communication challenges. The findings of this study may shed light on the unique conditions faced by clinicians, particularly in relation to communication, in the complex trilingual healthcare context of an emergency department similar to those in Hong Kong, and provide potential policy solutions for barriers to improve communication in such settings. © 2016 John Wiley & Sons Ltd.

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors

PubMed Central

Palmer, Katherine A; Shane, Rita; Wu, Cindy N; Bell, Douglas S; Diaz, Frank; Cook-Wiens, Galen; Jackevicius, Cynthia A

2016-01-01

Objective We sought to assess the potential of a widely available source of electronic medication data to prevent medication history errors and resultant inpatient order errors. Methods We used admission medication history (AMH) data from a recent clinical trial that identified 1017 AMH errors and 419 resultant inpatient order errors among 194 hospital admissions of predominantly older adult patients on complex medication regimens. Among the subset of patients for whom we could access current Surescripts electronic pharmacy claims data (SEPCD), two pharmacists independently assessed error severity and our main outcome, which was whether SEPCD (1) was unrelated to the medication error; (2) probably would not have prevented the error; (3) might have prevented the error; or (4) probably would have prevented the error. Results Seventy patients had both AMH errors and current, accessible SEPCD. SEPCD probably would have prevented 110 (35%) of 315 AMH errors and 46 (31%) of 147 resultant inpatient order errors. When we excluded the least severe medication errors, SEPCD probably would have prevented 99 (47%) of 209 AMH errors and 37 (61%) of 61 resultant inpatient order errors. SEPCD probably would have prevented at least one AMH error in 42 (60%) of 70 patients. Conclusion When current SEPCD was available for older adult patients on complex medication regimens, it had substantial potential to prevent AMH errors and resultant inpatient order errors, with greater potential to prevent more severe errors. Further study is needed to measure the benefit of SEPCD in actual use at hospital admission. PMID:26911817

Medication Reconciliation and Therapy Management in Dialysis-Dependent Patients: Need for a Systematic Approach

PubMed Central

Cardone, Katie E.; Manley, Harold J.; St. Peter, Wendy L.; Shaffer, Rachel; Somers, Michael; Mehrotra, Rajnish

2013-01-01

Summary Patients with ESRD undergoing dialysis have highly complex medication regimens and disproportionately higher total cost of care compared with the general Medicare population. As shown by several studies, dialysis-dependent patients are at especially high risk for medication-related problems. Providing medication reconciliation and therapy management services is critically important to avoid costs associated with medication-related problems, such as adverse drug events and hospitalizations in the ESRD population. The Medicare Modernization Act of 2003 included an unfunded mandate stipulating that medication therapy management be offered to high-risk patients enrolled in Medicare Part D. Medication management services are distinct from the dispensing of medications and involve a complete medication review for all disease states. The dialysis facility is a logical coordination center for medication management services, like medication therapy management, and it is likely the first health care facility that a patient will present to after a care transition. A dedicated and adequately trained clinician, such as a pharmacist, is needed to provide consistent, high-quality medication management services. Medication reconciliation and medication management services that could consistently and systematically identify and resolve medication-related problems would be likely to improve ESRD patient outcomes and reduce total cost of care. Herein, this work provides a review of available evidence and recommendations for optimal delivery of medication management services to ESRD patients in a dialysis facility-centered model. PMID:23990162

Expanding patient access to quality medication-related information: the potential of medication hotlines to improve patient adherence in schizophrenia.

PubMed

Pettit, Amy R; Marcus, Steven C

2015-05-01

Medication nonadherence is a widespread problem that compromises treatment outcomes, particularly in schizophrenia. Weersink et al. (Soc Psychiatry Psychiatr Epidemiol, 2015) describe telephone calls to a national medicines information line, with a focus on queries related to antipsychotic medications. Their analysis of callers' questions and concerns offers a valuable window into patient and caregiver perspectives. Given that many callers reported that they had not shared these concerns with a health care provider, this study also highlights the capacity of medication hotlines to address unmet needs. Establishing and maintaining long-term treatment regimens is a complex task, and truly patient-centered care requires a variety of creative and accessible support resources. Medication lines have the potential to serve as a resource and to provide proactive and timely adherence support.

Children with medical complexity in Canada

PubMed Central

Dewan, Tammie; Cohen, Eyal

2013-01-01

The burden of chronic disease is placing pressure on the Canadian health care system. A small but important chronic disease population is children with medical complexity, defined as individuals with: high family-identified needs; complex chronic disease necessitating specialized care; functional disability; and high health care utilization. These patients present a challenge to community providers who are expected to provide holistic care and manage complex issues, often with a paucity of services and supports. Alternative models of care may address the complex needs of this population. In addition, strategies can be implemented in community practices that may assist with the care of children with medical complexity such as collaborative care, engagement of key workers, focus on goal-directed care and use of care plans. The paediatric community should engage in health care reform discussions focused on chronic disease to ensure that the complex needs of these children are met. PMID:24497777

Zolpidem ingestion, automatisms, and sleep driving: a clinical and legal case series.

PubMed

Poceta, J Steven

2011-12-15

To describe zolpidem-associated complex behaviors, including both daytime automatisms and sleep-related parasomnias. A case series of eight clinical patients and six legal defendants is presented. Patients presented to the author after an episode of confusion, amnesia, or somnambulism. Legal defendants were being prosecuted for driving under the influence, and the author reviewed the cases as expert witness for the defense. Potential predisposing factors including comorbidities, social situation, physician instruction, concomitant medications, and patterns of medication management were considered. Patients and defendants exhibited abnormal behavior characterized by poor motor control and confusion. Although remaining apparently interactive with the environment, all reported amnesia for 3 to 5 hours. In some cases, the episodes began during daytime wakefulness because of accidental or purposeful ingestion of the zolpidem and are considered automatisms. Other cases began after ingestion of zolpidem at the time of going to bed and are considered parasomnias. Risk factors for both wake and sleep-related automatic complex behaviors include the concomitant ingestion of other sedating drugs, a higher dose of zolpidem, a history of parasomnia, ingestion at times other than bedtime or when sleep is unlikely, poor management of pill bottles, and living alone. In addition, similar size and shape of two medications contributed to accidental ingestion in at least one case. Sleep driving and other complex behaviors can occur after zolpidem ingestion. Physicians should assess patients for potential risk factors and inquire about parasomnias. Serious legal and medical complications can occur as a result of these forms of automatic complex behaviors.

A national survey of residents in combined Internal Medicine and Dermatology residency programs: educational experience and future plans.

PubMed

Mostaghimi, Arash; Wanat, Karolyn; Crotty, Bradley H; Rosenbach, Misha

2015-10-16

In response to a perceived erosion of medical dermatology, combined internal medicine and dermatology programs (med/derm) programs have been developed that aim to train dermatologists who take care of medically complex patients. Despite the investment in these programs, there is currently no data with regards to the potential impact of these trainees on the dermatology workforce. To determine the experiences, motivations, and future plans of residents in combined med/derm residency programs. We surveyed residents at all United States institutions with both categorical and combined training programs in spring of 2012. Respondents used visual analog scales to rate clinical interests, self-assessed competency, career plans, and challenges. The primary study outcomes were comfort in taking care of patients with complex disease, future practice plans, and experience during residency. Twenty-eight of 31 med/derm residents (87.5%) and 28 of 91 (31%) categorical residents responded (overall response rate 46%). No significant differences were seen in self-assessed dermatology competency, or comfort in performing inpatient consultations, cosmetic procedures, or prescribing systemic agents. A trend toward less comfort in general dermatology was seen among med/derm residents. Med/derm residents were more likely to indicate career preferences for performing inpatient consultation and taking care of medically complex patients. Categorical residents rated their programs and experiences more highly. Med/derm residents have stronger interests in serving medically complex patients. Categorical residents are more likely to have a positive experience during residency. Future work will be needed to ascertain career choices among graduates once data are available.

Gaming science innovations to integrate health systems science into medical education and practice

PubMed Central

White, Earla J; Lewis, Joy H; McCoy, Lise

2018-01-01

Health systems science (HSS) is an emerging discipline addressing multiple, complex, interdependent variables that affect providers’ abilities to deliver patient care and influence population health. New perspectives and innovations are required as physician leaders and medical educators strive to accelerate changes in medical education and practice to meet the needs of evolving populations and systems. The purpose of this paper is to introduce gaming science as a lens to magnify HSS integration opportunities in the scope of medical education and practice. Evidence supports gaming science innovations as effective teaching and learning tools to promote learner engagement in scientific and systems thinking for decision making in complex scenarios. Valuable insights and lessons gained through the history of war games have resulted in strategic thinking to minimize risk and save lives. In health care, where decisions can affect patient and population outcomes, gaming science innovations have the potential to provide safe learning environments to practice crucial decision-making skills. Research of gaming science limitations, gaps, and strategies to maximize innovations to further advance HSS in medical education and practice is required. Gaming science holds promise to equip health care teams with HSS knowledge and skills required for transformative practice. The ultimate goals are to empower providers to work in complex systems to improve patient and population health outcomes and experiences, and to reduce costs and improve care team well-being.

Gaming science innovations to integrate health systems science into medical education and practice.

PubMed

White, Earla J; Lewis, Joy H; McCoy, Lise

2018-01-01

Health systems science (HSS) is an emerging discipline addressing multiple, complex, interdependent variables that affect providers' abilities to deliver patient care and influence population health. New perspectives and innovations are required as physician leaders and medical educators strive to accelerate changes in medical education and practice to meet the needs of evolving populations and systems. The purpose of this paper is to introduce gaming science as a lens to magnify HSS integration opportunities in the scope of medical education and practice. Evidence supports gaming science innovations as effective teaching and learning tools to promote learner engagement in scientific and systems thinking for decision making in complex scenarios. Valuable insights and lessons gained through the history of war games have resulted in strategic thinking to minimize risk and save lives. In health care, where decisions can affect patient and population outcomes, gaming science innovations have the potential to provide safe learning environments to practice crucial decision-making skills. Research of gaming science limitations, gaps, and strategies to maximize innovations to further advance HSS in medical education and practice is required. Gaming science holds promise to equip health care teams with HSS knowledge and skills required for transformative practice. The ultimate goals are to empower providers to work in complex systems to improve patient and population health outcomes and experiences, and to reduce costs and improve care team well-being.

Improved Organizational Outcomes Associated With Incorporation of Early Clinical Experiences for Second-Year Student Pharmacists at an Academic Medical Center.

PubMed

Pinelli, Nicole R; McLaughlin, Jacqueline E; Chen, Sheh-Li; Luter, David N; Arnall, Justin; Smith, Shayna; Roth, Mary T; Rodgers, Philip T; Williams, Dennis M; Amerine, Lindsey B

2017-02-01

To assess the feasibility of engaging second professional year student pharmacists in the medication reconciliation process on hospital and health system pharmacy practice outcomes. Student pharmacists in their second professional year in the Doctor of Pharmacy degree program at our institution were randomly selected from volunteers to participate. Each participant completed training prior to completing three 5-hour evening shifts. Organizational metrics, student pharmacist perception regarding quality of interactions with health care professionals, and pharmacist perceptions were collected. A total of 83 medication histories were performed on complex medical patients (57.0 ± 19.2 years, 51% female, 65% Caucasian, 12 ± 6 medications); of those, 93% were completed within 24 hours of hospital admission. Second professional student pharmacists completed on average 1.9 ± 0.6 medication histories per shift (range 1-3). Student pharmacists identified 0.9 medication-related problems per patient in collaboration with a pharmacist preceptor. Student pharmacists believed the quality of their interactions with health care professionals in the Student Medication and Reconciliation Team (SMART) program was good or excellent. The program has been well received by clinical pharmacists involved in its design and implementation. This study provides evidence that second professional year student pharmacists can assist pharmacy departments in the care of medically complex patients upon hospital admission.

A comparison of adherence to hypoglycemic medications between Type 2 diabetes patients with and without serious mental illness

PubMed Central

Kreyenbuhl, Julie; Leith, Jaclyn; Medoff, Deborah R.; Fang, LiJuan; Dickerson, Faith B.; Brown, Clayton H.; Goldberg, Richard W.; Potts, Wendy; Dixon, Lisa B.

2011-01-01

Inadequate self-management of chronic medical conditions like Type 2 diabetes may play a role in the poor health status of individuals with serious mental illnesses. We compared adherence to hypoglycemic medications and blood glucose control between 44 diabetes patients with a serious mental illness and 30 patients without a psychiatric illness. The two groups did not differ in their ability to manage a complex medication regimen as assessed by a performance-based measure of medication management capacity. However, significantly fewer patients with a mental illness self-reported nonadherence to their hypoglycemic regimens compared to those without a mental illness. Although individuals with mental illnesses also had better control of blood glucose, this metabolic parameter was not correlated with adherence to hypoglycemic medications in either patient group. The experience of managing a chronic mental illness may confer advantages to individuals with serious mental illnesses in the self-care of co-occurring medical conditions like Type 2 diabetes. PMID:21459458

Medication adherence monitoring: implications for patients and providers.

PubMed

Gheorghiu, Bobby; Nayani, Seema

2018-05-01

Non-adherence to medication is a key worldwide issue and can lead to adverse patient outcomes and increased health system costs. Would a process facilitating notification of non-adherence infringe upon the autonomy of individuals or breach expectations of privacy? In contrast, patients who are not taking their medication could unknowingly be putting themselves at risk and all the while prescribers are unaware and without the opportunity to intervene. With the advent of electronic methods of medication adherence monitoring, this ethical dilemma now involves a new layer of complexity. We present two scenarios encountered in clinical practice that reflect issues occurring regularly in the Canadian healthcare system.

Capturing the experiences of patients across multiple complex interventions: a meta-qualitative approach.

PubMed

Webster, Fiona; Christian, Jennifer; Mansfield, Elizabeth; Bhattacharyya, Onil; Hawker, Gillian; Levinson, Wendy; Naglie, Gary; Pham, Thuy-Nga; Rose, Louise; Schull, Michael; Sinha, Samir; Stergiopoulos, Vicky; Upshur, Ross; Wilson, Lynn

2015-09-08

The perspectives, needs and preferences of individuals with complex health and social needs can be overlooked in the design of healthcare interventions. This study was designed to provide new insights on patient perspectives drawing from the qualitative evaluation of 5 complex healthcare interventions. Patients and their caregivers were recruited from 5 interventions based in primary, hospital and community care in Ontario, Canada. We included 62 interviews from 44 patients and 18 non-clinical caregivers. Our team analysed the transcripts from 5 distinct projects. This approach to qualitative meta-evaluation identifies common issues described by a diverse group of patients, therefore providing potential insights into systems issues. This study is a secondary analysis of qualitative data; therefore, no outcome measures were identified. We identified 5 broad themes that capture the patients' experience and highlight issues that might not be adequately addressed in complex interventions. In our study, we found that: (1) the emergency department is the unavoidable point of care; (2) patients and caregivers are part of complex and variable family systems; (3) non-medical issues mediate patients' experiences of health and healthcare delivery; (4) the unanticipated consequences of complex healthcare interventions are often the most valuable; and (5) patient experiences are shaped by the healthcare discourses on medically complex patients. Our findings suggest that key assumptions about patients that inform intervention design need to be made explicit in order to build capacity to better understand and support patients with multiple chronic diseases. Across many health systems internationally, multiple models are being implemented simultaneously that may have shared features and target similar patients, and a qualitative meta-evaluation approach, thus offers an opportunity for cumulative learning at a system level in addition to informing intervention design and modification. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Hospital dental practice in special patients

PubMed Central

Silvestre-Rangil, Javier; Espín-Gálvez, Fernando

2014-01-01

Dental patients with special needs are people with different systemic diseases, multiple disorders or severe physical and/or mental disabilities. A Medline search was made, yielding a total of 29 articles that served as the basis for this study, which offers a brief description of the dental intervention protocols in medically compromised patients. Dental treatment in patients with special needs, whether presenting medical problems or disabilities, is sometimes complex. For this reason the hospital should be regarded as the ideal setting for the care of these individuals. Before starting any dental intervention, a correct patient evaluation is needed, based on a correct anamnesis, medical records and interconsultation reports, and with due assessment of the medical risks involved. The hospital setting offers the advantage of access to electronic medical records and to data referred to any complementary tests that may have been made, and we moreover have the possibility of performing treatments under general anesthesia. In this context, ambulatory major surgery is the best approach when considering general anesthesia in patients of this kind. Key words:Hospital dentistry, special patients, medically compromised patients. PMID:24121921

The complexity of managing COPD exacerbations: a grounded theory study of European general practice

PubMed Central

Risør, Mette Bech; Spigt, Mark; Iversen, R; Godycki-Cwirko, M; Francis, N; Altiner, A; Andreeva, E; Kung, K; Melbye, H

2013-01-01

Objectives To understand the concerns and challenges faced by general practitioners (GPs) and respiratory physicians about primary care management of acute exacerbations in patients with chronic obstructive pulmonary disease (COPD). Design 21 focus group discussions (FGDs) were performed in seven countries with a Grounded Theory approach. Each country performed three rounds of FGDs. Setting Primary and secondary care in Norway, Germany, Wales, Poland, Russia, The Netherlands, China (Hong Kong). Participants 142 GPs and respiratory physicians were chosen to include urban and rural GPs as well as hospital-based and out patient-clinic respiratory physicians. Results Management of acute COPD exacerbations is dealt with within a scope of concerns. These concerns range from ‘dealing with comorbidity’ through ‘having difficult patients’ to ‘confronting a hopeless disease’. The first concern displays medical uncertainty regarding diagnosis, medication and hospitalisation. These clinical processes become blurred by comorbidity and the social context of the patient. The second concern shows how patients receive the label ‘difficult’ exactly because they need complex attention, but even more because they are time consuming, do not take responsibility and are non-compliant. The third concern relates to the emotional reactions by the physicians when confronted with ‘a hopeless disease’ due to the fact that most of the patients do not improve and the treatment slows down the process at best. GPs and respiratory physicians balance these concerns with medical knowledge and practical, situational knowledge, trying to encompass the complexity of a medical condition. Conclusions Knowing the patient is essential when dealing with comorbidities as well as with difficult relations in the consultations on exacerbations. This study suggests that it is crucial to improve the collaboration between primary and secondary care, in terms of, for example, shared consultations and defined work tasks, which may enhance shared knowledge of patients, medical decision-making and improved management planning. PMID:24319274

A patient with autism and severe depression: medical and ethical challenges for an adolescent medicine unit.

PubMed

Skinner, S Rachel; Ng, Cindy; McDonald, Ann; Walters, Tamara

2005-10-17

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.

Medication communication between nurses and doctors for paediatric acute care: An ethnographic study.

PubMed

Borrott, Narelle; Kinney, Sharon; Newall, Fiona; Williams, Allison; Cranswick, Noel; Wong, Ian; Manias, Elizabeth

2017-07-01

To examine how communication between nurses and doctors occurred for managing medications in inpatient paediatric settings. Communication between health professionals influences medication incidents' occurrence and safe care. An ethnographic study was undertaken. Semi-structured interviews, observations and focus groups were conducted in three clinical areas of an Australian tertiary paediatric hospital. Data were transcribed verbatim and thematically analysed using the Medication Communication Model. The actual communication act revealed health professionals' commitment to effective medication management and the influence of professional identities on medication communication. Nurses and doctors were dedicated to providing safe, effective medication therapy for children, within their scope of practice and perceived role responsibilities. Most nurses and junior doctors used tentative language in their communication while senior doctors tended to use direct language. Irrespective of language style, nurses actively engaged with doctors to promote patients' needs. Yet, the medical hierarchical structure, staffing and attendant expectations influenced communication for medication management, causing frustration among nurses and doctors. Doctors' lack of verbal communication of documented changes to medication orders particularly troubled nurses. Nurses persisted in their efforts to acquire appropriate orders for safe medication administration to paediatric patients. Collaborative practice between nurses and doctors involved complex, symbiotic relationships. Their dedication to providing safe medication therapy to paediatric patients facilitated effective medication management. At times, shortcomings in interdisciplinary communication impacted on potential and actual medication incidents. Understanding of the complexities affecting medication communication between nurses and doctors helps to ensure interprofessional respect for each other's roles and inherent demands. Interdisciplinary education delivered in healthcare organisations would facilitate greater clarity in communication related to medications. Encouraging the use of concise, clear words in communication would help to promote improved understanding between parties, and accuracy and efficacy of medication management. © 2016 John Wiley & Sons Ltd.

Quantifying the medication burden of kidney transplant recipients in the first year post-transplantation.

PubMed

Low, Jac Kee; Crawford, Kimberley; Manias, Elizabeth; Williams, Allison

2018-06-28

Background Kidney transplantation is an effective treatment, but it is not a cure. Since the risk of graft rejection and the presence of comorbid conditions remain for a lifetime, medications are necessary. Objective To examine the prescription medication burden of adult kidney transplant recipients from 3- to 12-months post-transplantation. Setting All five adult kidney transplant units in Victoria, Australia. Method As part of a larger intervention study, we conducet a retrospective review of prescription refill records and medical records containing the history of medication changes of 64 participants who completed the study was undertaken. The complexity of the medication management was studied, and we looked at the burden of maintaining the medications supply. Outcome measures Pill burden, administration frequency, dose changes frequency, immunosuppressive medication changes, the estimated out-of-pocket costs of medications and frequency of pharmacy visits. Results At 3 months, the average daily pill burden was 22 (SD = 9) whilst at 12 months, it was 23 (SD = 10). Some participants required long-term prophylaxis of fungal infections up to 4 times a day whilst those with diabetes had to manage up to 4 insulin doses a day. The average out-of-pocket cost per person and the frequency of pharmacy visits at 6, 9 and 12 months post-transplantation remained relatively unchanged. Conclusion The medication regimen prescribed for kidney transplant recipients is complex and for most patients, it did not simplify over time post transplantation. Strategies are needed to support patients in managing the complexity of their medication regimen following kidney transplantation.

A Spanish Pillbox App for Elderly Patients Taking Multiple Medications: Randomized Controlled Trial

PubMed Central

Mira, José Joaquín; Navarro, Isabel; Botella, Federico; Borrás, Fernando; Orozco, Domingo; Iglesias-Alonso, Fuencisla; Pérez-Pérez, Pastora; Lorenzo, Susana; Toro, Nuria

2014-01-01

Background Nonadherence and medication errors are common among patients with complex drug regimens. Apps for smartphones and tablets are effective for improving adherence, but they have not been tested in elderly patients with complex chronic conditions and who typically have less experience with this type of technology. Objective The objective of this study was to design, implement, and evaluate a medication self-management app (called ALICE) for elderly patients taking multiple medications with the intention of improving adherence and safe medication use. Methods A single-blind randomized controlled trial was conducted with a control and an experimental group (N=99) in Spain in 2013. The characteristics of ALICE were specified based on the suggestions of 3 nominal groups with a total of 23 patients and a focus group with 7 professionals. ALICE was designed for Android and iOS to allow for the personalization of prescriptions and medical advice, showing images of each of the medications (the packaging and the medication itself) together with alerts and multiple reminders for each alert. The randomly assigned patients in the control group received oral and written information on the safe use of their medications and the patients in the experimental group used ALICE for 3 months. Pre and post measures included rate of missed doses and medication errors reported by patients, scores from the 4-item Morisky Medication Adherence Scale (MMAS-4), level of independence, self-perceived health status, and biochemical test results. In the experimental group, data were collected on their previous experience with information and communication technologies, their rating of ALICE, and their perception of the level of independence they had achieved. The intergroup intervention effects were calculated by univariate linear models and ANOVA, with the pre to post intervention differences as the dependent variables. Results Data were obtained from 99 patients (48 and 51 in the control and experimental groups, respectively). Patients in the experimental group obtained better MMAS-4 scores (P<.001) and reported fewer missed doses of medication (P=.02). ALICE only helped to significantly reduce medication errors in patients with an initially higher rate of errors (P<.001). Patients with no experience with information and communication technologies reported better adherence (P<.001), fewer missed doses (P<.001), and fewer medication errors (P=.02). The mean satisfaction score for ALICE was 8.5 out of 10. In all, 45 of 51 patients (88%) felt that ALICE improved their independence in managing their medications. Conclusions The ALICE app improves adherence, helps reduce rates of forgetting and of medication errors, and increases perceived independence in managing medication. Elderly patients with no previous experience with information and communication technologies are capable of effectively using an app designed to help them take their medicine more safely. Trial Registration Clinicaltrials.gov NCT02071498; http://clinicaltrials.gov/ct2/show/NCT02071498 (Archived by WebCite at http://www.webcitation.org/6OJjdHVhD). PMID:24705022

A Spanish pillbox app for elderly patients taking multiple medications: randomized controlled trial.

PubMed

Mira, José Joaquín; Navarro, Isabel; Botella, Federico; Borrás, Fernando; Nuño-Solinís, Roberto; Orozco, Domingo; Iglesias-Alonso, Fuencisla; Pérez-Pérez, Pastora; Lorenzo, Susana; Toro, Nuria

2014-04-04

Nonadherence and medication errors are common among patients with complex drug regimens. Apps for smartphones and tablets are effective for improving adherence, but they have not been tested in elderly patients with complex chronic conditions and who typically have less experience with this type of technology. The objective of this study was to design, implement, and evaluate a medication self-management app (called ALICE) for elderly patients taking multiple medications with the intention of improving adherence and safe medication use. A single-blind randomized controlled trial was conducted with a control and an experimental group (N=99) in Spain in 2013. The characteristics of ALICE were specified based on the suggestions of 3 nominal groups with a total of 23 patients and a focus group with 7 professionals. ALICE was designed for Android and iOS to allow for the personalization of prescriptions and medical advice, showing images of each of the medications (the packaging and the medication itself) together with alerts and multiple reminders for each alert. The randomly assigned patients in the control group received oral and written information on the safe use of their medications and the patients in the experimental group used ALICE for 3 months. Pre and post measures included rate of missed doses and medication errors reported by patients, scores from the 4-item Morisky Medication Adherence Scale (MMAS-4), level of independence, self-perceived health status, and biochemical test results. In the experimental group, data were collected on their previous experience with information and communication technologies, their rating of ALICE, and their perception of the level of independence they had achieved. The intergroup intervention effects were calculated by univariate linear models and ANOVA, with the pre to post intervention differences as the dependent variables. Data were obtained from 99 patients (48 and 51 in the control and experimental groups, respectively). Patients in the experimental group obtained better MMAS-4 scores (P<.001) and reported fewer missed doses of medication (P=.02). ALICE only helped to significantly reduce medication errors in patients with an initially higher rate of errors (P<.001). Patients with no experience with information and communication technologies reported better adherence (P<.001), fewer missed doses (P<.001), and fewer medication errors (P=.02). The mean satisfaction score for ALICE was 8.5 out of 10. In all, 45 of 51 patients (88%) felt that ALICE improved their independence in managing their medications. The ALICE app improves adherence, helps reduce rates of forgetting and of medication errors, and increases perceived independence in managing medication. Elderly patients with no previous experience with information and communication technologies are capable of effectively using an app designed to help them take their medicine more safely. Clinicaltrials.gov NCT02071498; http://clinicaltrials.gov/ct2/show/NCT02071498.

Implementing Medical Teaching Policy in University Hospitals

ERIC Educational Resources Information Center

Engbers, Rik; Fluit, Cornelia Cornelia R. M. G.; Bolhuis, Sanneke; de Visser, Marieke; Laan, Roland F. J. M.

2017-01-01

Within the unique and complex settings of university hospitals, it is difficult to implement policy initiatives aimed at developing careers in and improving the quality of academic medical teaching because of the competing domains of medical research and patient care. Factors that influence faculty in making use of teaching policy incentives have…

Comparison and alignment of an academic medical center's strategic goals with ASHP initiatives.

PubMed

Engels, Melanie J; Chaffee, Bruce W; Clark, John S

2015-12-01

An academic medical center's strategic goals were compared and aligned with the 2015 ASHP Health-System Pharmacy Initiative and the Pharmacy Practice Model Initiative (PPMI). The department's pharmacy practice model steering committee identified potential solutions to narrow prioritized gaps using a modified nominal group technique and a multivoting dot technique. Five priority solutions were identified and assigned to work groups to develop business plans, which included admission medication history and reconciliation for high-risk patients and those with complex medication regimens, pharmacist provision of discharge counseling to high-risk patients and those with complex medication regimens, improved measurement and reporting of the impact of PPMI programs on patient outcomes, implementation of a departmentwide formalized peer review and evaluation process, and the greeting of every patient at some time during his or her visit by a pharmacy team member. Stakeholders evaluated the business plans based on feasibility, financial return on investment, and anticipated safety enhancements. The solution that received the highest priority ranking and was subsequently implemented was "improved measurement and reporting of the impact of PPMI programs on patient outcomes." A defined process was followed for identifying gaps among current practices at an academic medical center and the 2015 ASHP Health-System Pharmacy Initiative and the PPMI. A key priority to better document the impact of pharmacists on patient care was identified for our department by using a nominal group technique brainstorming process and a multivoting dot technique and creating standardized business plans for five potential priority projects. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Social learning: medical student perceptions of geriatric house calls.

PubMed

Abbey, Linda; Willett, Rita; Selby-Penczak, Rachel; McKnight, Roberta

2010-01-01

Bandura's social learning theory provides a useful conceptual framework to understand medical students' perceptions of a house calls experience at Virginia Commonwealth University School of Medicine. Social learning and role modeling reflect Liaison Committee on Medical Education guidelines for "Medical schools (to) ensure that the learning environment for medical students promotes the development of explicit and appropriate professional attributes (attitudes, behaviors, and identity) in their medical students." This qualitative study reports findings from open-ended survey questions from 123 medical students who observed a preceptor during house calls to elderly homebound patients. Their comments included reflections on the medical treatment as well as interactions with family and professional care providers. Student insights about the social learning process they experienced during house calls to geriatric patients characterized physician role models as dedicated, compassionate, and communicative. They also described patient care in the home environment as comprehensive, personalized, more relaxed, and comfortable. Student perceptions reflect an appreciation of the richness and complexity of details learned from home visits and social interaction with patients, families, and caregivers.

[Medical ethical aspects of culture in social interactions with Muslim patients].

PubMed

Ilkilic, I

2007-07-30

In today's world, the plurality of values is considered to be a constitutive feature of modern societies. In these societies, transcultural patient-physician relationships are a part of daily medical practice. Culturally determined value systems can be crucial for understanding the perception of notions such as "health" and "illness", leading to fundamental differences in assessing medical interventions and therapeutic objectives. Therefore, transcultural conflicts of interest are presenting medical ethical decision-making with new challenges. Time and again, medical practice demonstrates that cultural differences between physician and patient are correlated with the complexity of medical ethical conflicts, as can be seen in the relationship between Muslim patients and non-Muslim physicians in the German health care system. This paper discusses some of the central issues in these relationships like communication, sense of shame, religious duties, and medical end-of-life decisions, analyzing some concrete cases. Subsequently, a number of medical ethical theses relevant for multicultural societies will be discussed.

Safe medication management in specialized home healthcare - an observational study.

PubMed

Lindblad, Marléne; Flink, Maria; Ekstedt, Mirjam

2017-08-24

Medication management is a complex, error-prone process. The aim of this study was to explore what constitutes the complexity of the medication management process (MMP) in specialized home healthcare and how healthcare professionals handle this complexity. The study is theoretically based in resilience engineering. Data were collected during the MMP at three specialized home healthcare units in Sweden using two strategies: observation of workplaces and shadowing RNs in everyday work, including interviews. Transcribed material was analysed using grounded theory. The MMP in home healthcare was dynamic and complex with unclear boundaries of responsibilities, inadequate information systems and fluctuating work conditions. Healthcare professionals adapted their everyday clinical work by sharing responsibility and simultaneously being authoritative and preserving patients' active participation, autonomy and integrity. To promote a safe MMP, healthcare professionals constantly re-prioritized goals, handled gaps in communication and information transmission at a distance by creating new bridging solutions. Trade-offs and workarounds were necessary elements, but also posed a threat to patient safety, as these interim solutions were not systematically evaluated or devised learning strategies. To manage a safe medication process in home healthcare, healthcare professionals need to adapt to fluctuating conditions and create bridging strategies through multiple parallel activities distributed over time, space and actors. The healthcare professionals' strategies could be integrated in continuous learning, while preserving boundaries of safety, instead of being more or less interim solutions. Patients' and family caregivers' as active partners in the MMP may be an underestimated resource for a resilient home healthcare.

Modeling Patient Treatment With Medical Records: An Abstraction Hierarchy to Understand User Competencies and Needs.

PubMed

St-Maurice, Justin D; Burns, Catherine M

2017-07-28

Health care is a complex sociotechnical system. Patient treatment is evolving and needs to incorporate the use of technology and new patient-centered treatment paradigms. Cognitive work analysis (CWA) is an effective framework for understanding complex systems, and work domain analysis (WDA) is useful for understanding complex ecologies. Although previous applications of CWA have described patient treatment, due to their scope of work patients were previously characterized as biomedical machines, rather than patient actors involved in their own care. An abstraction hierarchy that characterizes patients as beings with complex social values and priorities is needed. This can help better understand treatment in a modern approach to care. The purpose of this study was to perform a WDA to represent the treatment of patients with medical records. The methods to develop this model included the analysis of written texts and collaboration with subject matter experts. Our WDA represents the ecology through its functional purposes, abstract functions, generalized functions, physical functions, and physical forms. Compared with other work domain models, this model is able to articulate the nuanced balance between medical treatment, patient education, and limited health care resources. Concepts in the analysis were similar to the modeling choices of other WDAs but combined them in as a comprehensive, systematic, and contextual overview. The model is helpful to understand user competencies and needs. Future models could be developed to model the patient's domain and enable the exploration of the shared decision-making (SDM) paradigm. Our work domain model links treatment goals, decision-making constraints, and task workflows. This model can be used by system developers who would like to use ecological interface design (EID) to improve systems. Our hierarchy is the first in a future set that could explore new treatment paradigms. Future hierarchies could model the patient as a controller and could be useful for mobile app development. ©Justin D St-Maurice, Catherine M Burns. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 28.07.2017.

Assessment of Unconscious Decision Aids Applied to Complex Patient-Centered Medical Decisions

PubMed Central

Manigault, Andrew Wilhelm; Whillock, Summer Rain

2015-01-01

Background To improve patient health, recent research urges for medical decision aids that are designed to enhance the effectiveness of specific medically related decisions. Many such decisions involve complex information, and decision aids that independently use deliberative (analytical and slower) or intuitive (more affective and automatic) cognitive processes for such decisions result in suboptimal decisions. Unconscious thought can arguably use both intuitive and deliberative (slow and analytic) processes, and this combination may further benefit complex patient (or practitioner) decisions as medical decision aids. Indeed, mounting research demonstrates that individuals render better decisions generally if they are distracted from thinking consciously about complex information after it is presented (but can think unconsciously), relative to thinking about that information consciously or not at all. Objective The current research tested whether the benefits of unconscious thought processes can be replicated using an Internet platform for a patient medical decision involving complex information. This research also explored the possibility that judgments reported after a period of unconscious thought are actually the result of a short period of conscious deliberation occurring during the decision report phase. Methods A total of 173 participants in a Web-based experiment received information about four medical treatments, the best (worst) associated with mostly positive (negative) side-effects/attributes and the others with equal positive-negative ratios. Next, participants were either distracted for 3 minutes (unconscious thought), instructed to think about the information for 3 minutes (conscious thought), or moved directly to the decision task (immediate decision). Finally, participants reported their choice of, and attitudes toward, the treatments while experiencing high, low, or no cognitive load, which varied their ability to think consciously while reporting judgments. Cognitive load was manipulated by having participants memorize semi-random (high), line structured (low), or no dot patterns and recall these intermittently with their decision reports. Overall then, participants were randomly assigned to the conditions of a 3 (thought condition) by 3 (cognitive-load level) between-subjects design. Results A logistic regression analysis indicated that the odds of participants choosing the best treatment were 2.25 times higher in the unconscious-thought condition compared to the immediate-decision condition (b=.81, Wald=4.32, P=.04, 95% CI 1.048-4.836), and 2.39 times greater compared to the conscious-thought condition (b=.87, Wald=4.87, P=.027, 95% CI 1.103-5.186). No difference was observed between the conscious-thought condition compared to the immediate-decision condition, and cognitive load manipulations did not affect choices or alter the above finding. Conclusions This research demonstrates a plausible benefit of unconscious thinking as a decision aid for complex medical decisions, and represents the first use of unconscious thought processes as a patient-centered medical decision aid. Further, the quality of decisions reached unconsciously does not appear to be affected by the amount of cognitive load participants experienced. PMID:25677337

A novel clinical decision support algorithm for constructing complete medication histories.

PubMed

Long, Ju; Yuan, Michael Juntao

2017-07-01

A patient's complete medication history is a crucial element for physicians to develop a full understanding of the patient's medical conditions and treatment options. However, due to the fragmented nature of medical data, this process can be very time-consuming and often impossible for physicians to construct a complete medication history for complex patients. In this paper, we describe an accurate, computationally efficient and scalable algorithm to construct a medication history timeline. The algorithm is developed and validated based on 1 million random prescription records from a large national prescription data aggregator. Our evaluation shows that the algorithm can be scaled horizontally on-demand, making it suitable for future delivery in a cloud-computing environment. We also propose that this cloud-based medication history computation algorithm could be integrated into Electronic Medical Records, enabling informed clinical decision-making at the point of care. Copyright © 2017 Elsevier B.V. All rights reserved.

Use of a medication quantification scale for comparison of pain medication usage in patients with complex regional pain syndrome (CRPS).

PubMed

Gallizzi, Michael A; Khazai, Ravand S; Gagnon, Christine M; Bruehl, Stephen; Harden, R Norman

2015-03-01

To correlate the amount and types of pain medications prescribed to CRPS patients, using the Medication Quantification Scale, and patients' subjective pain levels. An international, multisite, retrospective review. University medical centers in the United States, Israel, Germany, and the Netherlands. A total of 89 subjects were enrolled from four different countries: 27 from the United States, 20 Germany, 18 Netherlands, and 24 Israel. The main outcome measures used were the Medication Quantification Scale III and numerical analog pain scale. There was no statistically significant correlation noted between the medication quantification scale and the visual analog scale for any site except for a moderate positive correlation at German sites. The medication quantification scale mean differences between the United States and Germany, the Netherlands, and Israel were 9.793 (P < 0.002), 10.389 (P < 0.001), and 4.984 (P = 0.303), respectively. There appears to be only a weak correlation between amount of pain medication prescribed and patients' reported subjective pain intensity within this limited patient population. The Medication Quantification Scale is a viable tool for the analysis of pharmaceutical treatment of CRPS patients and would be useful in further prospective studies of pain medication prescription practices in the CRPS population worldwide. Wiley Periodicals, Inc.

A Cooperative Communication System for the Advancement of Safe, Effective, and Efficient Patient Care

DTIC Science & Technology

2015-09-01

graphical display to promote acute change detection in ICU patients. International Journal of Medical Informatics , 81(12), 842-851. Brooke, J. (1996...patient history timeline. In this instance, the window describes the event causing injury (an oil rig explosion) and diagnosis upon admission Figures A...solutions to overcome them. Despite years of effort in medical informatics , a gap remains between the complexities of the clinical work setting and the

Complex psychotropic polypharmacy in bipolar disorder across varying mood polarities: A prospective cohort study of 2712 inpatients.

PubMed

Golden, Julia C; Goethe, John W; Woolley, Stephen B

2017-10-15

It is common for patients with bipolar disorder (BP) to receive multiple psychotropics, but few studies have assessed demographic and clinical features associated with risk for receiving complex psychotropic polypharmacy. This longitudinal cohort study examined 2712 inpatients with a DSM-IV clinical diagnosis of BP to assess associations between complex polypharmacy (defined as ≥4 psychotropics) and demographic and clinical features; associations with risk of rehospitalization were also examined. Logistic regressions were performed with the sample as a whole and with each of four DSM-IV BP subtypes individually. Complex polypharmacy was present in 21.0%. BP-I depressed patients were more likely to receive complex regimens than BP-I manic, BP-I mixed or BP-II patients. In the sample as a whole, variables significantly associated with complex polypharmacy included female, white, psychotic features and a co-diagnosis of borderline personality, post-traumatic stress or another anxiety disorder. The only examined medication not significantly associated with complex polypharmacy was lithium, although only in BP-I depressed and BP-I mixed. Complex polypharmacy was associated with rehospitalization in BP-I mania within 15 and 30days post index hospitalization. All data were from one clinical facility; results may not generalize to other settings and patient populations. BP-I depression may pose a greater treatment challenge than the other BP subtypes. Lithium may confer an overall advantage compared to other medications in BP-I depressed and BP-I mixed. Further research is needed to guide pharmacotherapy decisions in BP patients. Copyright © 2017 Elsevier B.V. All rights reserved.

Medication adherence and persistence in type 2 diabetes mellitus: perspectives of patients, physicians and pharmacists on the Spanish health care system

PubMed Central

Labrador Barba, Elena; Rodríguez de Miguel, Marta; Hernández-Mijares, Antonio; Alonso-Moreno, Francisco Javier; Orera Peña, Maria Luisa; Aceituno, Susana; Faus Dader, María José

2017-01-01

Objective A good relationship between diabetes patients and their health care team is crucial to ensure patients’ medication adherence and self-management. To this end, we aimed to identify and compare the views of type 2 diabetes mellitus (T2DM) patients, physicians and pharmacists concerning the factors and strategies that may be associated with, or could improve, medication adherence and persistence. Methods An observational, cross-sectional study was conducted using an electronic self-administered questionnaire comprising 11 questions (5-point Likert scale) concerning factors and strategies related to medication adherence. The survey was designed for T2DM patients and Spanish National Health System professionals. Results A total of 963 T2DM patients, 998 physicians and 419 pharmacists participated in the study. Overall, a lower proportion of pharmacists considered the proposed factors associated with medication adherence important as compared to patients and physicians. It should be noted that a higher percentage of physicians in comparison to pharmacists perceived that “complexity of medication” (97% vs 76.6%, respectively) and “adverse events” (97.5% vs 72.2%, respectively) were important medication-related factors affecting adherence. In addition, both patients (80.8%) and physicians (80.8%) agreed on the importance of “cost and co-payment” for adherence, whereas only 48.6% of pharmacists considered this factor important. It is also noteworthy that nearly half of patients (43%) agreed that “to adjust medication to activities of daily living” was the best strategy to reduce therapeutic complexity, whereas physicians believed that “reducing the frequency of administration” (47.9%) followed by “reducing the number of tablets” (28.5%) was the most effective strategy to improve patients’ adherence. Conclusion Our results highlight the need for pharmacists to build a stronger relationship with physicians in order to improve patients monitoring and adherence rates. Additionally, these findings may help to incorporate greater patient-centeredness when developing management strategies, focusing on adjusting medication regimens to patients’ daily lives. PMID:28435229

Treatment interruptions and non-adherence with imatinib and associated healthcare costs: a retrospective analysis among managed care patients with chronic myelogenous leukaemia.

PubMed

Darkow, Theodore; Henk, Henry J; Thomas, Simu K; Feng, Weiwei; Baladi, Jean-Francois; Goldberg, George A; Hatfield, Alan; Cortes, Jorge

2007-01-01

Identify treatment interruptions and non-adherence with imatinib; examine the clinical and patient characteristics related to treatment interruptions and non-adherence; and estimate the association between treatment interruptions and non-adherence with imatinib and healthcare costs for US managed care patients with chronic myeloid leukaemia (CML). This retrospective analysis utilised electronic healthcare claims data from a US managed care provider. Adult patients with CML (as determined by International Classification of Diseases, ninth revision, Clinical Modification [ICD-9-CM] diagnosis code) were identified who began treatment with imatinib from 1 June 2001 through 31 March 2004. Treatment interruptions (i.e. failure to refill imatinib within 30 days from the run-out date of the prior prescription) were identified during the 12-month follow-up period. Medication possession ratio (MPR), calculated as total days' supply of imatinib divided by 365, was also examined. Healthcare costs (i.e. paid amounts for all prescription medications and medical services received, including health plan and patient liability) were examined in three ways: (i) total healthcare costs; (ii) total healthcare costs exclusive of imatinib costs; and (iii) total medical costs. All costs were converted to US dollars (2004 values) using the medical component of the Consumer Price Index. MPR was modelled using ordinary least squares regression. Presence of treatment interruptions was modelled using logistic regression. The association between MPR and healthcare costs was estimated using a generalised linear model specified with a gamma error distribution and a log link. All models included adjustment for age, gender, number of concomitant medications, starting dose of imatinib and cancer complexity. A total of 267 patients were identified. Average age was approximately 50 years, and 43% were women. Mean MPR was 77.7%, with 31% of patients having a treatment interruption. However, all of these patients resumed imatinib within the study period. In this population, MPR decreased as the number of concomitant medications increased (p = 0.002), and was lower among women (p = 0.003), patients with high cancer complexity (p = 0.003) and patients with a higher starting dose of imatinib (p = 0.04). Women were approximately twice as likely as men to have a treatment interruption (p = 0.009), as were patients with a high cancer complexity (p = 0.03). After adjusting for the aforementioned covariates, MPR was found to be inversely associated with healthcare costs excluding imatinib (p < 0.001) and medical costs (p < 0.001). A 10% point difference in MPR was associated with a 14% difference in healthcare costs excluding imatinib and a 15% difference in medical costs. For example, patients with an MPR of 75% incur an additional 4072 US dollars in medical costs annually compared with patients with an MPR of 85%. Treatment interruptions and non-adherence with imatinib, both of which could lead to undesired clinical and economic outcomes, appear to be prevalent. Physicians and pharmacists should educate patients and closely monitor adherence to therapy, as improving adherence and limiting treatment interruptions may not only optimise clinical outcomes but also reduce the economic burden of CML.

Zolpidem Ingestion, Automatisms, and Sleep Driving: A Clinical and Legal Case Series

PubMed Central

Poceta, J. Steven

2011-01-01

Study Objectives: To describe zolpidem-associated complex behaviors, including both daytime automatisms and sleep-related parasomnias. Methods: A case series of eight clinical patients and six legal defendants is presented. Patients presented to the author after an episode of confusion, amnesia, or somnambulism. Legal defendants were being prosecuted for driving under the influence, and the author reviewed the cases as expert witness for the defense. Potential predisposing factors including comorbidities, social situation, physician instruction, concomitant medications, and patterns of medication management were considered. Results: Patients and defendants exhibited abnormal behavior characterized by poor motor control and confusion. Although remaining apparently interactive with the environment, all reported amnesia for 3 to 5 hours. In some cases, the episodes began during daytime wakefulness because of accidental or purposeful ingestion of the zolpidem and are considered automatisms. Other cases began after ingestion of zolpidem at the time of going to bed and are considered parasomnias. Risk factors for both wake and sleep-related automatic complex behaviors include the concomitant ingestion of other sedating drugs, a higher dose of zolpidem, a history of parasomnia, ingestion at times other than bedtime or when sleep is unlikely, poor management of pill bottles, and living alone. In addition, similar size and shape of two medications contributed to accidental ingestion in at least one case. Conclusions: Sleep driving and other complex behaviors can occur after zolpidem ingestion. Physicians should assess patients for potential risk factors and inquire about parasomnias. Serious legal and medical complications can occur as a result of these forms of automatic complex behaviors. Citation: Poceta JS. Zolpidem ingestion, automatisms, and sleep driving: a clinical and legal case series. J Clin Sleep Med 2011;7(6):632-638. PMID:22171202

Complexity in graduate medical education: a collaborative education agenda for internal medicine and geriatric medicine.

PubMed

Chang, Anna; Fernandez, Helen; Cayea, Danelle; Chheda, Shobhina; Paniagua, Miguel; Eckstrom, Elizabeth; Day, Hollis

2014-06-01

Internal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.

Modeling Patient Treatment With Medical Records: An Abstraction Hierarchy to Understand User Competencies and Needs

PubMed Central

2017-01-01

Background Health care is a complex sociotechnical system. Patient treatment is evolving and needs to incorporate the use of technology and new patient-centered treatment paradigms. Cognitive work analysis (CWA) is an effective framework for understanding complex systems, and work domain analysis (WDA) is useful for understanding complex ecologies. Although previous applications of CWA have described patient treatment, due to their scope of work patients were previously characterized as biomedical machines, rather than patient actors involved in their own care. Objective An abstraction hierarchy that characterizes patients as beings with complex social values and priorities is needed. This can help better understand treatment in a modern approach to care. The purpose of this study was to perform a WDA to represent the treatment of patients with medical records. Methods The methods to develop this model included the analysis of written texts and collaboration with subject matter experts. Our WDA represents the ecology through its functional purposes, abstract functions, generalized functions, physical functions, and physical forms. Results Compared with other work domain models, this model is able to articulate the nuanced balance between medical treatment, patient education, and limited health care resources. Concepts in the analysis were similar to the modeling choices of other WDAs but combined them in as a comprehensive, systematic, and contextual overview. The model is helpful to understand user competencies and needs. Future models could be developed to model the patient’s domain and enable the exploration of the shared decision-making (SDM) paradigm. Conclusion Our work domain model links treatment goals, decision-making constraints, and task workflows. This model can be used by system developers who would like to use ecological interface design (EID) to improve systems. Our hierarchy is the first in a future set that could explore new treatment paradigms. Future hierarchies could model the patient as a controller and could be useful for mobile app development. PMID:28754650

"Real-life" treatment of chronic pain: Targets and goals.

PubMed

Ablin, Jacob N; Buskila, Dan

2015-02-01

Treating chronic pain is a complex challenge. While textbooks and medical education classically categorize pain as originating from peripheral (nociceptive), neuropathic, or centralized origins, in real life each and every patient may present a combination of various pain sources, types, and mechanisms. Moreover, individual patients may evolve and develop differing types of pain throughout their clinical follow-up, further emphasizing the necessity to maintain clinical diligence during the evaluation and follow-up of these patients. Rational treatment of patients suffering from chronic pain must attempt at deconstructing complex pain cases, identifying variegate pain generators, and targeting them with appropriate interventions, while incorporating both pharmacological and non-pharmacological strategies, rather than focusing on the total pain level, which represents an integral of all pain types. Failing to recognize the coexistence of different types of pain in an individual patient and escalating medications only on the basis of total pain intensity are liable to lead to both ineffective control of pain and increased untoward effects. In the current review, we outline strategies for deconstructing complex pain and therapeutic suggestions. Copyright © 2015 Elsevier Ltd. All rights reserved.

What is it like to take antipsychotic medication? A qualitative study of patients with first-episode psychosis.

PubMed

Gray, R; Deane, K

2016-03-01

What is known on the subject? Antipsychotic drugs are an important part of treatment for most patients with first episode psychosis. We do not know much about what it is like to take these drugs from the patient's point of view. What this paper adds to existing knowledge? We talked to 20 young people with psychosis about their experiences of taking antipsychotic drugs. Patients relationship with medication was complex, young people found medication often to be both good and bad at the same time. We were interested in how seemingly trivial issues--colour, taste, size, name--could be very important to young people and could result in them stopping. What are the implications for practice? We think our study highlights the complicated internal struggles that people with first episode psychosis have with medication. Our study highlights how Nurses and Doctors need to try and better understand what it is like to take these drugs and work collaboratively with patients to support them to make informed choices about treatment. Low-dose antipsychotic medication is an important part of treatment for people experiencing a first episode of psychosis. Little is known about this group of patients' experiences of taking medication. A qualitative study of purposively sampled young people experiencing a first episode of psychosis was carried out. A mental health nurse working in the early psychosis team interviewed participants using a structured topic guide. Interviews were subjected to thematic analysis. Interviews were completed with 20 young people. Thematic analysis generated six themes: (1) the drugs do work, (2) the drugs don't work (as well as I'd like), (3) side effects, (4) the indirect effects of medication, (5) rage against the machine and (6) the not trivial issues about medication. Our overarching meta-theme was that young people's experience of taking antipsychotics was complex; medication was often considered good and bad at the same time. Our observations underpin the importance of helping patients think through the use of antipsychotic medication in supporting their personal recovery. © 2016 John Wiley & Sons Ltd.

In-home behavioral health case management: an integrated model for high-risk populations.

PubMed

Theis, Gerald A; Kozlowski, Deirdre; Behrens, Jenna

2006-01-01

The escalating health care costs attributed to high-risk populations have fueled a need for a proactive approach to deal with people affected by complex mental health issues that often coexist with chronic medical conditions. Through an in-home behavioral health case management (CM) program, patients with mental illnesses (some with coexisting medical conditions) receive integrated medical and mental health services through a disease-management approach that has proven effective in treating high-risk patients.

The ethics of the medical-pharmaceutical relationship.

PubMed

Vashi, Neelam A; Latkowski, Jo-Ann M

2012-01-01

Physician interaction with the pharmaceutical industry raises many ethical concerns. This relationship is complex, owing to a pluralism of beliefs held by physicians, patients, and third parties. As a result, determining whether physicians fulfill their responsibilities to both the professional and public communities is an arduous endeavor. In an effort to clarify the situation and provide transparency to this complex relationship, medical and pharmaceutical organizations have enacted their own respective codes and guidelines. Even with adherence to these guidelines, questions remain regarding the codependent relationship that interweaves the pharmaceutical industry with the medical community. Owing to the ever-changing landscape enmeshing product development, scientific advancement, corporate realities and patient care, the proper choice for physicians is rarely obvious; however, to operate to the highest standards, those in the medical community must be candid about relations with the pharmaceutical industry and transparent in their financial interests. Further undertakings should focus not on the eradication of physician-pharmaceutical interaction, but instead on the education of physicians about industry marketing strategies and the delineation of boundaries of these interactions to benefit not the individual physician, but our patients. Copyright © 2012. Published by Elsevier Inc.

Behavioral health coaching for rural veterans with diabetes and depression: a patient randomized effectiveness implementation trial.

PubMed

Cully, Jeffrey A; Breland, Jessica Y; Robertson, Suzanne; Utech, Anne E; Hundt, Natalie; Kunik, Mark E; Petersen, Nancy J; Masozera, Nicholas; Rao, Radha; Naik, Aanand D

2014-04-28

Depression and diabetes cause significant burden for patients and the healthcare system and, when co-occurring, result in poorer self-care behaviors and worse glycemic control than for either condition alone. However, the clinical management of these comorbid conditions is complicated by a host of patient, provider, and system-level barriers that are especially problematic for patients in rural locations. Patient-centered medical homes provide an opportunity to integrate mental and physical health care to address the multifaceted needs of complex comorbid conditions. Presently, there is a need to not only develop robust clinical interventions for complex medically ill patients but also to find feasible ways to embed these interventions into the frontlines of existing primary care practices. This randomized controlled trial uses a hybrid effectiveness-implementation design to evaluate the Healthy Outcomes through Patient Empowerment (HOPE) intervention, which seeks to simultaneously address diabetes and depression for rural veterans in Southeast Texas. A total of 242 Veterans with uncontrolled diabetes and comorbid symptoms of depression will be recruited and randomized to either the HOPE intervention or to a usual-care arm. Participants will be evaluated on a host of diabetes and depression-related measures at baseline and 6- and 12-month follow-up. The trial has two primary goals: 1) to examine the effectiveness of the intervention on both physical (diabetes) and emotional health (depression) outcomes and 2) to simultaneously pilot test a multifaceted implementation strategy designed to increase fidelity and utilization of the intervention by coaches interfacing within the primary care setting. This ongoing blended effectiveness-implementation design holds the potential to advance the science and practice of caring for complex medically ill patients within the constraints of a busy patient-centered medical home. Behavioral Activation Therapy for Rural Veterans with Diabetes and Depression: NCT01572389.

Biochemical and genetic analysis of Leigh syndrome patients in Korea.

PubMed

Chae, Jong-Hee; Lee, Jin Sook; Kim, Ki Joong; Hwang, Yong Seung; Hirano, Michio

2008-06-01

Sixteen Korean patients with Leigh syndrome were identified at the Seoul National University Children's Hospital in 2001-2006. Biochemical or molecular defects were identified in 14 patients (87.5%). Thirteen patients had respiratory chain enzyme defects; 9 had complex I deficiency, and 4 had combined defects of complex I+III+IV. Based on the biochemical defects, targeted genetic studies in 4 patients with complex I deficiency revealed two heteroplasmic mitochondrial DNA mutations in ND genes. One patient had the mitochondrial DNA T8993G point mutation. No mitochondrial DNA defects were identified in 11 (68.7%) of our LS patients, who probably have mutations in nuclear DNA. Although a limited study based in a single tertiary medical center, our findings suggest that isolated complex I deficiency may be the most common cause of Leigh syndrome in Korea.

Somatopsychic correlates and quality of life of the dialyzed patient: a cross-sectional study.

PubMed

De Pasquale, C; Pistorio, M L; Lauretta, I; Fatuzzo, P; Fornaro, M; Conti, D; Di Nuovo, S; Sinagra, N; Giaquinta, A; Zerbo, D; Veroux, M

2014-09-01

The dialysis delivered after a chronic kidney disease (CDK) or any otherwise severe end-stage renal failure is a complex medical task, leading to major medical and psychopathological distress for the patient. The aim of the present study was to analyze the impact of the dialysis experience on the nephrologic patient's global quality of life. In the present cross-sectional study, involving 96 patients with end-stage renal disease receiving hemodialysis, demographic, medical, and psychological differential features across different CDK diagnoses were accounted and were then correlated each other. Among other differential features, the "acknowledgement of dependence" (from the medical device delivering the dialysis) emerged as a factor correlated to "self-sufficiency" in CDK patients receiving hemodialysis. Although further, larger-sampled studies on the topic are needed, medical and psychological interventions are useful to ensure a better global quality of life and good therapeutic adherence in dialysis patients. Copyright © 2014 Elsevier Inc. All rights reserved.

Visual representation of medical information: the importance of considering the end-user in the design of medical illustrations.

PubMed

Scheltema, Emma; Reay, Stephen; Piper, Greg

2018-01-01

This practice led research project explored visual representation through illustrations designed to communicate often complex medical information for different users within Auckland City Hospital, New Zealand. Media and tools were manipulated to affect varying degrees of naturalism or abstraction from reality in the creation of illustrations for a variety of real-life clinical projects, and user feedback on illustration preference gathered from both medical professionals and patients. While all users preferred the most realistic representations of medical information from the illustrations presented, patients often favoured illustrations that depicted a greater amount of information than professionals suggested was necessary.

Effectiveness of a complex intervention on Prioritising Multimedication in Multimorbidity (PRIMUM) in primary care: results of a pragmatic cluster randomised controlled trial.

PubMed

Muth, Christiane; Uhlmann, Lorenz; Haefeli, Walter E; Rochon, Justine; van den Akker, Marjan; Perera, Rafael; Güthlin, Corina; Beyer, Martin; Oswald, Frank; Valderas, Jose Maria; Knottnerus, J André; Gerlach, Ferdinand M; Harder, Sebastian

2018-02-24

Investigate the effectiveness of a complex intervention aimed at improving the appropriateness of medication in older patients with multimorbidity in general practice. Pragmatic, cluster randomised controlled trial with general practice as unit of randomisation. 72 general practices in Hesse, Germany. 505 randomly sampled, cognitively intact patients (≥60 years, ≥3 chronic conditions under pharmacological treatment, ≥5 long-term drug prescriptions with systemic effects); 465 patients and 71 practices completed the study. Intervention group (IG): The healthcare assistant conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision support system, the general practitioner optimised medication, discussed it with patients and adjusted it accordingly. The control group (CG) continued with usual care. The primary outcome was a modified Medication Appropriateness Index (MAI, excluding item 10 on cost-effectiveness), assessed in blinded medication reviews and calculated as the difference between baseline and after 6 months; secondary outcomes after 6 and 9 months' follow-up: quality of life, functioning, medication adherence, and so on. At baseline, a high proportion of patients had appropriate to mildly inappropriate prescriptions (MAI 0-5 points: n=350 patients). Randomisation revealed balanced groups (IG: 36 practices/252 patients; CG: 36/253). Intervention had no significant effect on primary outcome: mean MAI sum scores decreased by 0.3 points in IG and 0.8 points in CG, resulting in a non-significant adjusted mean difference of 0.7 (95% CI -0.2 to 1.6) points in favour of CG. Secondary outcomes showed non-significant changes (quality of life slightly improved in IG but continued to decline in CG) or remained stable (functioning, medication adherence). The intervention had no significant effects. Many patients already received appropriate prescriptions and enjoyed good quality of life and functional status. We can therefore conclude that in our study, there was not enough scope for improvement. ISRCTN99526053. NCT01171339; Results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Titrating guidance: a model to guide physicians in assisting patients and family members who are facing complex decisions.

PubMed

Goldstein, Nathan E; Back, Anthony L; Morrison, R Sean

2008-09-08

Over the last century, developments in new medical treatments have led to an exponential increase in longevity, but, as a consequence, patients may be left with chronic illness associated with long-term severe functional and cognitive disability. Patients and their families are often forced to make a difficult and complex choice between death and long-term debility, neither of which is an acceptable outcome. Traditional models of medical decision making, however, do not fully address how clinicians should best assist with these decisions. Herein, we present a new paradigm that demonstrates how the role of the physician changes over time in response to the curved relationship between the predictability of a patient's outcome and the chance of returning to an acceptable quality of life. To translate this model into clinical practice, we propose a 5-step model for physicians with which they can (1) determine at which point the patient is on our model; (2) identify the cognitive factors and preferences for outcomes that affect the decision-making process of the patient and his or her family; (3) reflect on their own reaction to the decision at hand; (4) acknowledge how these factors can be addressed in conversation; and (5) guide the patient and his or her family in creating a plan of care. This model can help improve patient-physician communication and decision making so that complex and difficult decisions can be turned into ones that yield to medical expertise, good communication, and personal caring.

Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem.

PubMed

Perez, Bianca; Knych, Stephen A; Weaver, Sallie J; Liberman, Aaron; Abel, Eileen M; Oetjen, Dawn; Wan, Thomas T H

2014-03-01

The issues of medical errors and medical malpractice have stimulated significant interest in establishing transparency in health care, in other words, ensuring that medical professionals formally report medical errors and disclose related outcomes to patients and families. However, research has amply shown that transparency is not a universal practice among physicians. A review of the literature was carried out using the search terms "transparency," "patient safety," "disclosure," "medical error," "error reporting," "medical malpractice," "doctor-patient relationship," and "physician" to find articles describing physician barriers to transparency. The current literature underscores that a complex Web of factors influence physician reluctance to engage in transparency. Specifically, 4 domains of barriers emerged from this analysis: intrapersonal, interpersonal, institutional, and societal. Transparency initiatives will require vigorous, interdisciplinary efforts to address the systemic and pervasive nature of the problem. Several ethical and social-psychological barriers suggest that medical schools and hospitals should collaborate to establish continuity in education and ensure that knowledge acquired in early education is transferred into long-term learning. At the institutional level, practical and cultural barriers suggest the creation of supportive learning environments and private discussion forums where physicians can seek moral support in the aftermath of an error. To overcome resistance to culture transformation, incremental change should be considered, for example, replacing arcane transparency policies and complex reporting mechanisms with clear, user-friendly guidelines.

Medical students' opportunities to participate and learn from activities at an internal medicine ward: an ethnographic study.

PubMed

Hägg-Martinell, A; Hult, H; Henriksson, P; Kiessling, A

2017-02-14

To optimise medical students' early clerkship is a complex task since it is conducted in a context primarily organised to take care of patients. Previous studies have explored medical students' perceptions of facilitation and hindrance of learning. However, the opportunities for medical student to learn within the culture of acute medicine care have not been fully investigated. This study aimed to explore how medical students approach, interact and socialise in an acute internal medicine ward context, and how spaces for learning are created and used in such a culture. Ethnographic observations were performed of medical students' interactions and learning during early clerkship at an acute internal medicine care ward. Field notes were taken, transcribed and analysed qualitatively. Data analysis was guided by Wenger's theory of communities of practice. 21 medical students and 30 supervisors participated. Two themes were identified: Nervousness and curiosity- students acted nervously and stressed, especially when they could not answer questions. Over time curiosity could evolve. Unexplored opportunities to support students in developing competence to judge and approach more complex patient-related problems were identified. Invited and involved -students were exposed to a huge variation of opportunities to learn, and to interact and to be involved. Short placements seemed to disrupt the learning process. If and how students became involved also depended on supervisors' activities and students' initiatives. This study shed light on how an acute internal medicine ward culture can facilitate medical students' possibilities to participate and learn. Medical students' learning situations were characterised by questions and answers rather than challenging dialogues related to the complexity of presented patient cases. Further, students experienced continuous transfers between learning situations where the potential to be involved differed in a wide variety of ways. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Physician Verbal Compliance-Gaining Strategies and Patient Satisfaction

ERIC Educational Resources Information Center

Olynick, Janna; Iliopulos, Alexandra; Li, Han Z.

2017-01-01

Purpose: The patient healthcare experience is a complex phenomenon, as is encouraging patient compliance with medical advice. To address this multifaceted relationship, the purpose of this paper is to explore the ways resident physicians verbally encourage patient compliance and the relationship between these compliance-seeking strategies and…

The loved ones: families, intimates and patient autonomy.

PubMed

O'Donovan, Katherine; Gilbar, Roy

2003-05-01

Patient autonomy is one of the central values in medical ethics. It is generally understood as recognition of patients' rights as free individuals answerable only to themselves. This emphasis on the individual leaves open the question of the position of the patients' 'loved ones', that is of families and significant others. The authors examine this question in three areas of law and medical ethics. Organ donation offers an example of preference given by medical ethics to family views, notwithstanding an expressed wish of the deceased to donate, and the legal position protecting such a request. Decisions concerning the treatment of incompetent patients illustrate consideration for the family in medical ethics, but hesitations in both law and ethics in accepting family views once expressed. And the tension between the interests of patients and family members over the access to genetic information usually results in respecting the patient's right to confidentiality. This individualistic perception of autonomy, as adopted by medical law, overlooks the patient's relationships with others and is too narrow to face the complexities of human lives.

The complexity of fetal imaging: reconciling clinical care with patient entertainment.

PubMed

Simonsen, Sara Ellis; Branch, D Ware; Rose, Nancy C

2008-12-01

Currently in the United States, pregnant women may obtain both medical fetal ultrasonography for screening and commercial fetal ultrasonography for entertainment purposes. The proliferation of commercial fetal ultrasonography suggests that medical screening alone does not satisfy patient expectations regarding fetal imaging. We investigated the prevalence of nonmedical fetal imaging and patient experiences and perceptions with both medical and nonmedical ultrasonography in our metropolitan area. We initiate a dialogue to explore the distinctions between medical and nonmedical fetal ultrasound imaging and the role of entertainment imaging in the medical setting. Concerns about safety, false reassurance, and unnecessary anxiety that might be generated by nonmedical ultrasonography should prompt us to examine the expectations of women regarding entertainment imaging, current clinical practice, and the potential for regulation of this commercial industry.

Proper care for the dying: a critical public issue.

PubMed Central

Crispell, K R; Gomez, C F

1987-01-01

The ability of the medical profession to sustain life, or more appropriately, to prolong dying, in patients with terminal illness, creates a most complex and controversial situation for all involved: the patient, if mentally alert; the patient's family; and the medical care team including physicians, nurses and attendants. This situation is especially complex in large acute care hospitals where medical and nursing students, residents and house officers receive advanced medical training. A major problem, prolonging the dying of the terminally ill, with its medical, legal, ethical and economic complexities now confronts American society. The problem is particularly acute in teaching hospitals, in which one finds a disproportionate number of terminally ill patients. The ability to work at these questions as a community rather than as adversaries will determine much about the ability of the health care system to respect the dignity and autonomy of those who seek aid and comfort when faced with serious illness and impending death. Better communication between the physicians, health care providers, the lawyers and ethicists must be developed in order to solve these problems. Over the next ten years society and our elected representatives will be making very demanding decisions about the use of the health dollar. One possible way to prevent increasing costs is to reach significant agreement on the proper care of the dying. Proper care for the dying is being considered, discussed, and evaluated by very thoughtful people. It is not governments which should decide who is to live or who is to die. There is the serious problem of the 'slippery slope' to euthanasia by omission if cost containment becomes the major force in formulating policy on the proper care of the dying. PMID:3612698

Ignorance isn't bliss: why patients become angry.

PubMed

Sonnenberg, Amnon

2015-06-01

Patients with cognitive limitations may struggle understanding complex arguments and feel overwhelmed by the need to choose among medical options that they poorly understand. Such struggle may result in frustration and anger directed at the physician. The aim of the present study is to explain the characteristics underlying such situations. A decision tree is modeled to capture the choice that every patient has to make after receiving medical advice. Patient choices are phrased in terms of a threshold probability for accepting or rejecting advice by physicians. To a patient with poor understanding of medical exigencies all differences between present or absent disease state, prognosis, and risks of intervention may seem largely arbitrary and meaningless. With little or no guidance to make an informed decision, taking any medical action is deemed wasted and harmful, whereas inaction leaves the underlying medical problem unsolved. Both choices appear equally ineffective with respect to the patient's symptoms and therefore unappealing. As shown by applying threshold analysis to a patient in a state of ignorance, no threshold probability for following medical advice exists. Patients with cognitive limitations will become frustrated and angry by a seemingly dismal situation without good alternatives to choose from.

The cost-effectiveness of psychotherapy for the major psychiatric diagnoses.

PubMed

Lazar, Susan G

2014-09-01

Psychotherapy is an effective and often highly cost-effective medical intervention for many serious psychiatric conditions. Psychotherapy can also lead to savings in other medical and societal costs. It is at times the firstline and most important treatment and at other times augments the efficacy of psychotropic medication. Many patients are in need of more prolonged and intensive psychotherapy, including those with personality disorders and those with chronic complex psychiatric conditions often with severe anxiety and depression. Many patients with serious and complex psychiatric illness have experienced severe early life trauma in an atmosphere in which family members or caretakers themselves have serious psychiatric disorders. Children and adolescents with learning disabilities and those with severe psychiatric disorders can also require more than brief treatment. Other diagnostic groups for whom psychotherapy is effective and cost-effective include patients with schizophrenia, anxiety disorders (including posttraumatic stress disorder), depression, and substance abuse. In addition, psychotherapy for the medically ill with concomitant psychiatric illness often lowers medical costs, improves recovery from medical illness, and at times even prolongs life compared to similar patients not given psychotherapy. While "cost-effective" treatments can yield savings in healthcare costs, disability claims, and other societal costs, "cost-effective" by no means translates to "cheap" but instead describes treatments that are clinically effective and provided at a cost that is considered reasonable given the benefit they provide, even if the treatments increase direct expenses. In the current insurance climate in which Mental Health Parity is the law, insurers nonetheless often use their own non-research and non-clinically based medical necessity guidelines to subvert it and limit access to appropriate psychotherapeutic treatments. Many patients, especially those who need extended and intensive psychotherapy, are at risk of receiving substandard care due to inadequate insurance reimbursement. These patients remain vulnerable to residual illness and the concomitant sequelae in lost productivity, dysfunctional interpersonal and family relationships, comorbidity including increased medical and surgical services, and increased mortality.

Communication relating to family members' involvement and understandings about patients' medication management in hospital.

PubMed

Manias, Elizabeth

2015-10-01

Many patients with complex health-care needs are prescribed several medications on a daily basis. With admission to hospital, patients are often placed in a vulnerable position. Family members can therefore play an important role in supporting patients in decision making about managing medications and negotiating communication exchange with health professionals. From the perspective of family members, to explore family members' involvement with health professionals and patients about how patients' medications are managed in hospital. Using an ethnographic design, interviews were conducted with family members of patients admitted to hospital who had at least five medications prescribed in hospital. A purposive sampling approach was used for recruitment. A thematic framework process was used for analysis. Interviews took place in four surgical and four medical wards in each of two Australian hospitals. Forty interviews were conducted with family members in relation to their respective relative's medications. Family members tended to participate in passive, rather than active or shared decision-making activities. Those who demonstrated active or shared decision making were extensively involved in managing medications and in addressing problems relating to continuity of care. Communication with health professionals was generally insufficient, despite family members' keenness to speak with them. Improved communication is needed between family members, health professionals and patients in hospitals. Greater attention should be played by health professionals in initiating communication proactively. Family members possessed valuable, unique information about patients' medications that can be utilized to facilitate patient safety. © 2013 Blackwell Publishing Ltd.

New IEEE 11073 Standards for interoperable, networked Point-of-Care Medical Devices.

PubMed

Kasparick, Martin; Schlichting, Stefan; Golatowski, Frank; Timmermann, Dirk

2015-08-01

Surgical procedures become more and more complex and the number of medical devices in an operating room (OR) increases continuously. Today's vendor-dependent solutions for integrated ORs are not able to handle this complexity. They can only form isolated solutions. Furthermore, high costs are a result of vendor-dependent approaches. Thus we present a service-oriented device communication for distributed medical systems that enables the integration and interconnection between medical devices among each other and to (medical) information systems, including plug-and-play functionality. This system will improve patient's safety by making technical complexity of a comprehensive integration manageable. It will be available as open standards that are part of the IEEE 11073 family of standards. The solution consists of a service-oriented communication technology, the so called Medical Devices Profile for Web Services (MDPWS), a Domain Information & Service Model, and a binding between the first two mechanisms. A proof of this concept has been done with demonstrators of real world OR devices.

Current trends in pharmacy benefit designs: a threat to disease management in chronic complex diseases.

PubMed

Owens, Gary; Emons, Matthew F; Christian-Herman, Jennifer; Lawless, Grant

2007-04-01

With a focus on those patients who are candidates for treatment with biologic agents, we review the impact that current pharmacy benefit trends have on patients with chronic complex diseases and how they affect opportunities for disease management in this unique patient population. Dramatic increases in health care costs have led to a variety of strategies to manage cost. Many of these strategies either limit access to care or increase the patient's responsibility for choosing and paying for care, especially for medications. These strategies have a disproportionate impact on patients with chronic complex diseases, particularly those who require the use of biologic medications. A fundamental prerequisite of disease management has been coverage of disease-modifying therapies. If current pharmacy benefit trends continue, unintended consequences will likely occur including lost opportunities for disease management. Current pharmacy benefit trends could adversely impact disease management, particularly for patients requiring the use of biologic agents. Health plans should consider innovative benefit designs that reflect an appropriate level of cost sharing across all key stake-holders, ensuring appropriate access to needed therapies. Additional research is needed to clarify the value of newer approaches to therapies or benefit design changes.

Clinical complexity and Occam's razor: navigating between Scylla and Charibdy of the geriatric practice. A case of secondary hypertension in a very old patient.

PubMed

Turco, Renato; Torpilliesi, Tiziana; Morghen, Sara; Bellelli, Giuseppe; Trabucchi, Marco

2009-05-01

The clinical approach toward elderly patients is often very complex and associated with an increased risk of medical errors. This case report is an example of how various objective (related to patient) and subjective (related to physicians) factors may influence the optimal diagnostic approach in elderly frail patients. We also discuss geriatric practice, which must be characterized by the intellectual honesty to refuse any sort of prejudices (such as ageism) and by the skill to navigate between the Scylla (ie, viewing clinical problems as unrelated to each other) and the Charibdy (ie, applying the Occam's razor principle) of the patient's complexity.

Using Complexity Theory to Guide Medical School Evaluations.

PubMed

Jorm, Christine; Roberts, Chris

2018-03-01

Contemporary medical school evaluations are narrow in focus and often do not consider the wider systems implications of the relationship between learning and teaching, research, clinical care, and community engagement. The result is graduates who lack the necessary knowledge and skills for the modern health care system and an educational system that is limited in its ability to learn and change.To address this issue, the authors apply complexity theory to medical school evaluation, using four key factors-nesting, diversity, self-organization, and emergent outcomes. To help medical educators apply this evaluation approach in their own settings, the authors offer two tools-a modified program logic model and sensemaking. In sensemaking, they use the organic metaphor of the medical school as a neuron situated within a complex neural network to enable medical educators to reframe the way they think about program evaluation. The authors then offer practical guidance for applying this model, including describing the example of addressing graduates' engagement in the health care system. The authors consider the input of teachers, the role of culture and curriculum, and the clinical care system in this example.Medical school evaluation is reframed as an improvement science for complex social interventions (medical school is such an intervention) in this model. With complexity theory's focus on emergent outcomes, evaluation takes on a new focus, reimagining medical students as reaching their future potential as change agents, who transform health systems and the lives of patients.

Managing complex patients on a medical psychiatric unit: an observational study of university hospital costs associated with medical service use, length of stay, and psychiatric intervention.

PubMed

Leue, Carsten; Driessen, Ger; Strik, Jacqueline J; Drukker, Marjan; Stockbrügger, Reinhold W; Kuijpers, Petra M; Masclee, Ad A; van Os, Jim

2010-03-01

Although there is a suggestion that the medical psychiatric unit (MPU) may reduce length of hospital stay (LOS), little is known about costs in terms of medical service use and psychiatric interventions in MPU care. A record linkage study was conducted, linking cost data of hospital medical service use, LOS, and hospital psychiatric interventions to patients admitted to the MPU of the Maastricht University Medical Centre (MUMC) between 1998 and 2004. The data set was analyzed to enable comparison between cost changes of the same complex patient population following either MPU index admission or index admissions to reference MUMC medical wards. Comparisons revealed lower costs of medical service use in favor of the MPU (-euro104; 95% CI -euro174 to -euro35; P<.01). However, cost of psychiatric intervention and cost of LOS were higher after MPU admission (respectively, +euro165; 95% CI +euro25 to +euro305; P<.05; and +euro202; 95% CI +euro170 to +euro235; P<.001). Total costs were higher after MPU admission compared to medical ward admission (+euro263; 95% CI +euro68 to +euro458; P<.05). These differences were not moderated by somatic diagnosis or previous pattern of admissions. The findings suggest that patients at the interface of psychiatric and somatic morbidity are diagnosed and treated adequately at the MPU, leading to a decrease in medical service use and an appropriate increase in exposure to psychiatric interventions. These results are specifically generalizable to MPUs with a focus on psychosomatic conditions, for instance, somatoform disorders or affective disorders with comorbid somatic diseases. However, failure to show cost savings in terms of LOS compared to medical wards outweighs cost-benefit derived from lower medical service use, suggesting that MPU activities may gain in cost-effectiveness if shifted more to outpatient psychosomatic care solutions. Copyright 2010 Elsevier Inc. All rights reserved.

Payment and Care for Hematopoietic Cell Transplantation Patients: Toward a Specialized Medical Home for Complex Care Patients.

PubMed

Gajewski, James L; McClellan, Mark B; Majhail, Navneet S; Hari, Parameswaran N; Bredeson, Christopher N; Maziarz, Richard T; LeMaistre, Charles F; Lill, Michael C; Farnia, Stephanie H; Komanduri, Krishna V; Boo, Michael J

2018-01-01

Patient-centered medical home models are fundamental to the advanced alternative payment models defined in the Medicare Access and Children's Health Insurance Plan Reauthorization Act (MACRA). The patient-centered medical home is a model of healthcare delivery supported by alternative payment mechanisms and designed to promote coordinated medical care that is simultaneously patient-centric and population-oriented. This transformative care model requires shifting reimbursement to include a per-patient payment intended to cover services not previously reimbursed such as disease management over time. Payment is linked to quality measures, including proportion of care delivered according to predefined pathways and demonstrated impact on outcomes. Some medical homes also include opportunities for shared savings by reducing overall costs of care. Recent proposals have suggested expanding the medical home model to specialized populations with complex needs because primary care teams may not have the facilities or the requisite expertise for their unique needs. An example of a successful care model that may provide valuable lessons for those creating specialty medical home models already exists in many hematopoietic cell transplantation (HCT) centers that deliver multidisciplinary, coordinated, and highly specialized care. The integration of care delivery in HCT centers has been driven by the specialty care their patients require and by the payment methodology preferred by the commercial payers, which has included bundling of both inpatient and outpatient care in the peritransplant interval. Commercial payers identify qualified HCT centers based on accreditation status and comparative performance, enabled in part by center-level comparative performance data available within a national outcomes database mandated by the Stem Cell Therapeutic and Research Act of 2005. Standardization across centers has been facilitated via voluntary accreditation implemented by Foundation for the Accreditation of Cell Therapy. Payers have built on these community-established programs and use public outcomes and program accreditation as standards necessary for inclusion in specialty care networks and contracts. Although HCT centers have not been described as medical homes, most HCT providers have already developed the structures that address critical requirements of MACRA for medical homes. Copyright © 2017 The American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

Medical marijuana and the developing role of the pharmacist.

PubMed

Seamon, Matthew J; Fass, Jennifer A; Maniscalco-Feichtl, Maria; Abu-Shraie, Nada A

2007-05-15

The pharmacology, therapeutic uses, safety, drug-drug interactions, and drug-disease interactions of medical marijuana are reviewed, and the legal issues related to its use and the implications of medical marijuana for the pharmacist are presented. Marijuana contains more than 460 active chemicals and over 60 unique cannabinoids. The legal landscape surrounding marijuana is surprisingly complex and unsettled. In the United States, 11 states and several municipalities have legalized medical marijuana. Another state provides legislation that allows patients to claim a defense of medical necessity. Nevertheless, patients using medical marijuana may never interact with a pharmacist. Marijuana is a Schedule I controlled substance and its use is illegal under federal law. Marijuana has a number of purported therapeutic uses with a broad range of supporting evidence. There are five general indications for medical marijuana: (1) severe nausea and vomiting associated with cancer chemotherapy or other causes, (2) weight loss associated with debilitating illnesses, including HIV infection and cancer, (3) spasticity secondary to neurologic diseases, such as multiple sclerosis, (4) pain syndromes, and (5) other uses, such as for glaucoma. Marijuana is associated with adverse psychiatric, cardiovascular, respiratory, and immunologic events. Moreover, marijuana may interact with a number of prescription drugs and concomitant disease states. Several states have legalized the use of marijuana for chronic and debilitating medication conditions. Pharmacists need to understand the complex legal framework surrounding this issue so that they can protect themselves and better serve their patients.

The consequences of using advanced physical assessment skills in medical and surgical nursing: A hermeneutic pragmatic study.

PubMed

Zambas, Shelaine I; Smythe, Elizabeth A; Koziol-Mclain, Jane

2016-01-01

The aim of this study was to explore the consequences of the nurse's use of advanced assessment skills on medical and surgical wards. Appropriate, accurate, and timely assessment by nurses is the cornerstone of maintaining patient safety in hospitals. The inclusion of "advanced" physical assessment skills such as auscultation, palpation, and percussion is thought to better prepare nurses for complex patient presentations within a wide range of clinical situations. This qualitative study used a hermeneutic pragmatic approach. Unstructured interviews were conducted with five experienced medical and surgical nurses to obtain 13 detailed narratives of assessment practice. Narratives were analyzed using Van Manen's six-step approach to identify the consequences of the nurse's use of advanced assessment skills. The consequences of using advanced assessment skills include looking for more, challenging interpretations, and perseverance. The use of advanced assessment skills directs what the nurse looks for, what she sees, interpretation of the findings, and her response. It is the interpretation of what is seen, heard, or felt within the full context of the patient situation, which is the advanced skill. Advanced assessment skill is the means to an accurate interpretation of the clinical situation and contributes to appropriate diagnosis and medical management in complex patient situations. The nurse's use of advanced assessment skills enables her to contribute to diagnostic reasoning within the acute medical and surgical setting.

[Monitoring medication errors in an internal medicine service].

PubMed

Smith, Ann-Loren M; Ruiz, Inés A; Jirón, Marcela A

2014-01-01

Patients admitted to internal medicine services receive multiple drugs and thus are at risk of medication errors. To determine the frequency of medication errors (ME) among patients admitted to an internal medicine service of a high complexity hospital. A prospective observational study conducted in 225 patients admitted to an internal medicine service. Each stage of drug utilization system (prescription, transcription, dispensing, preparation and administration) was directly observed by trained pharmacists not related to hospital staff during three months. ME were described and categorized according to the National Coordinating Council for Medication Error Reporting and Prevention. In each stage of medication use, the frequency of ME and their characteristics were determined. A total of 454 drugs were prescribed to the studied patients. In 138 (30,4%) indications, at least one ME occurred, involving 67 (29,8%) patients. Twenty four percent of detected ME occurred during administration, mainly due to wrong time schedules. Anticoagulants were the therapeutic group with the highest occurrence of ME. At least one ME occurred in approximately one third of patients studied, especially during the administration stage. These errors could affect the medication safety and avoid achieving therapeutic goals. Strategies to improve the quality and safe use of medications can be implemented using this information.

Centralized care management support for "high utilizers" in primary care practices at an academic medical center.

PubMed

Williams, Brent C; Paik, Jamie L; Haley, Laura L; Grammatico, Gina M

2014-01-01

Although evidence of effectiveness is limited, care management based outside primary care practices or hospitals is receiving increased attention. The University of Michigan (UM) Complex Care Management Program (CCMP) provides care management for uninsured and underinsured, high-utilizing patients in multiple primary care practices. To inform development of optimal care management models, we describe the CCMP model and characteristics and health care utilization patterns of its patients. Of a consecutive series of 49 patients enrolled at CCMP in 2011, the mean (SD) age was 48 (+/- 14); 23 (47%) were women; and 29 (59%) were White. Twenty-eight (57%) had two or more chronic medical conditions, 39 (80%) had one or more psychiatric condition, 28 (57%) had a substance abuse disorder, and 11 (22%) were homeless. Through phone, e-mail, and face-to-face contact with patients and primary care providers (PCPs), care managers coordinated health and social services and facilitated access to medical and mental health care. Patients had a mean (SD) number of hospitalizations and emergency room (ER) visits in 6 months prior to enrollment of2.2 (2.5) and 4.2 (4.3), respectively, with a nonstatistically significant decrease in hospitalizations, hospital days, and emergency room visits in 6 months following enrollment in CCMP. Centralized care management support for primary care practices engages high-utilizing patients with complex medical and behavioral conditions in care management that would be difficult to provide through individual practices and may decrease health care utilization by these patients.

Producing Tomorrow's Doctor: The New Challenge for Today's Undergraduate Medical Curriculum

ERIC Educational Resources Information Center

Roberts, Mike

2004-01-01

The training and education of doctors is a complex process. The traditional apprenticeship model of clinical medical education following a pre-clinical sciences curriculum had many strengths and produced a doctor who met the needs of several generations of patients. More recently, medical training has been criticised for not adapting to the more…

Improving Our Nation's Health Care System: Inclusion of Chiropractic in Patient-Centered Medical Homes and Accountable Care Organizations

PubMed Central

Meeker, William C.; Watkins, R.W.; Kranz, Karl C.; Munsterman, Scott D.; Johnson, Claire

2014-01-01

Objective This report summarizes the closing plenary session of the Association of Chiropractic Colleges Educational Conference—Research Agenda Conference 2014. The purpose of this session was to examine patient-centered medical homes and accountable care organizations from various speakers’ viewpoints and to discuss how chiropractic could possibly work within, and successfully contribute to, the changing health care environment. Discussion The speakers addressed the complex topic of patient-centered medical homes and accountable care organizations and provided suggestions for what leadership strategies the chiropractic profession may need to enhance chiropractic participation and contribution to improving our nation’s health. Conclusion There are many factors involved in the complex topic of chiropractic inclusion in health care models. Major themes resulting from this panel included the importance of building relationships with other professionals, demonstrating data and evidence for what is done in chiropractic practice, improving quality of care, improving health of populations, and reducing costs of health care. PMID:25431542

Visualization index for image-enabled medical records

NASA Astrophysics Data System (ADS)

Dong, Wenjie; Zheng, Weilin; Sun, Jianyong; Zhang, Jianguo

2011-03-01

With the widely use of healthcare information technology in hospitals, the patients' medical records are more and more complex. To transform the text- or image-based medical information into easily understandable and acceptable form for human, we designed and developed an innovation indexing method which can be used to assign an anatomical 3D structure object to every patient visually to store indexes of the patients' basic information, historical examined image information and RIS report information. When a doctor wants to review patient historical records, he or she can first load the anatomical structure object and the view the 3D index of this object using a digital human model tool kit. This prototype system helps doctors to easily and visually obtain the complete historical healthcare status of patients, including large amounts of medical data, and quickly locate detailed information, including both reports and images, from medical information systems. In this way, doctors can save time that may be better used to understand information, obtain a more comprehensive understanding of their patients' situations, and provide better healthcare services to patients.

The patient-centered medical home neighbor: A primary care physician's view.

PubMed

Sinsky, Christine A

2011-01-04

The American College of Physicians' position paper on the patient-centered medical home neighbor (PCMH-N) extends the work of the patient-centered medical home (PCMH) as a means of improving the delivery of health care. Recognizing that the PCMH does not exist in isolation, the PCMH-N concept outlines expectations for comanagement, communication, and care coordination and broadens responsibility for safe, effective, and efficient care beyond primary care to include physicians of all specialties. As such, it is a fitting follow-up to the PCMH and moves further down the road toward improved care for complex patients. Yet, there is more work to be done. Truly transforming the U.S. health care system around personalized medical homes embedded in highly functional medical neighborhoods will require better staffing models; more robust electronic information tools; aligned incentives for quality and efficiency within payment and regulatory policies; and a culture of greater engagement of patients, their families, and communities.

Family medicine outpatient encounters are more complex than those of cardiology and psychiatry.

PubMed

Katerndahl, David; Wood, Robert; Jaén, Carlos Roberto

2011-01-01

comparison studies suggest that the guideline-concordant care provided for specific medical conditions is less optimal in primary care compared with cardiology and psychiatry settings. The purpose of this study is to estimate the relative complexity of patient encounters in general/family practice, cardiology, and psychiatry settings. secondary analysis of the 2000 National Ambulatory Medical Care Survey data for ambulatory patients seen in general/family practice, cardiology, and psychiatry settings was performed. The complexity for each variable was estimated as the quantity weighted by variability and diversity. there is minimal difference in the unadjusted input and total encounter complexity of general/family practice and cardiology; psychiatry's input is less complex. Cardiology encounters involved more input quantitatively, but the diversity of general/family practice input eliminated the difference. Cardiology also involved more complex output. However, when the duration of visit is factored in, the complexity of care provided per hour in general/family practice is 33% more relative to cardiology and 5 times more relative to psychiatry. care during family physician visits is more complex per hour than the care during visits to cardiologists or psychiatrists. This may account for a lower rate of completion of process items measured for quality of care.

Acute Care Management of the HIV-Infected Patient: A Report from the HIV Practice and Research Network of the American College of Clinical Pharmacy.

PubMed

Durham, Spencer H; Badowski, Melissa E; Liedtke, Michelle D; Rathbun, R Chris; Pecora Fulco, Patricia

2017-05-01

Patients infected with human immunodeficiency virus (HIV) admitted to the hospital have complex antiretroviral therapy (ART) regimens with an increased medication error rate upon admission. This report provides a resource for clinicians managing HIV-infected patients and ART in the inpatient setting. A survey of the authors was conducted to evaluate common issues that arise during an acute hospitalization for HIV-infected patients. After a group consensus, a review of the medical literature was performed to determine the supporting evidence for the following HIV-associated hospital queries: admission/discharge orders, antiretroviral hospital formularies, laboratory monitoring, altered hepatic/renal function, drug-drug interactions (DDIs), enteral administration, and therapeutic drug monitoring. With any hospital admission for an HIV-infected patient, a specific set of procedures should be followed including a thorough admission medication history and communication with the ambulatory HIV provider to avoid omissions or substitutions in the ART regimen. DDIs are common and should be reviewed at all transitions of care during the hospital admission. ART may be continued if enteral nutrition with a feeding tube is deemed necessary, but the entire regimen should be discontinued if no oral access is available for a prolonged period. Therapeutic drug monitoring is not generally recommended but, if available, should be considered in unique clinical scenarios where antiretroviral pharmacokinetics are difficult to predict. ART may need adjustment if hepatic or renal insufficiency ensues. Treatment of hospitalized patients with HIV is highly complex. HIV-infected patients are at high risk for medication errors during various transitions of care. Baseline knowledge of the principles of antiretroviral pharmacotherapy is necessary for clinicians managing acutely ill HIV-infected patients to avoid medication errors, identify DDIs, and correctly dose medications if organ dysfunction arises. Timely ambulatory follow-up is essential to prevent readmissions and facilitate improved transitions of care. © 2017 Pharmacotherapy Publications, Inc.

Update on chronic complex patient malnutrition

PubMed

Álvarez Hernández, Julia

2017-05-08

The Scientific Committee of the Sociedad Española de Nutrición Parenteral y Enteral (SENPE) and the Nutricia Advanced Medical Nutrition company began this Course some years ago, and now, it is a referent course in the multidisciplinary training of Clinical Nutrition. With this issue we review the advances in Clinical Nutrition in different situations and, this year, the topic is the malnutrition in chronic complex patients.

Case Study: Hidden Complexity of Medicines Use: Information Provided by a Person with Intellectual Disability and Diabetes to a Pharmacist

ERIC Educational Resources Information Center

Flood, Bernadette; Henman, Martin C.

2015-01-01

People with intellectual disabilities may be "invisible" to pharmacists. They are a complex group of patients many of whom have diabetes. Pharmacists may have little experience of the challenges faced by this high risk group of patients who may be prescribed high risk medications. This case report details information supplied by Pat, a…

Improving Care for Children With Complex Needs

ClinicalTrials.gov

2017-10-10

Medically Complex Children; Care Coordination; Case Manager; Care Manager; Collaborative Care; Disease Management; Patient Care Team or Organization; Managed Care; Children With Chronic Conditions; Children With Special Health Care Needs; Shared Care Plan; Patient Care Plan; Health Care and Resource Utilization; Adherence to Care; Functional Status and Productivity; Health Related Quality of Life; Satisfaction With Care; Care Coordinator; Family Experience of Care; Quality Health Care

Undertreatment of COPD: a retrospective analysis of US managed care and Medicare patients.

PubMed

Make, Barry; Dutro, Michael P; Paulose-Ram, Ryne; Marton, Jenö P; Mapel, Douglas W

2012-01-01

We investigated a large population of patients with chronic obstructive pulmonary disease (COPD) to determine their frequency of medication use and patterns of pharmacotherapy. Medical and pharmacy claims data were retrospectively analyzed from 19 health plans (>7.79 million members) across the US. Eligible patients were aged ≥40 years, continuously enrolled during July 2004 to June 2005, and had at least one inpatient or at least two outpatient claims coded for COPD. As a surrogate for severity of illness, COPD patients were stratified by complexity of illness using predefined International Classification of Diseases, Ninth Revision, Clinical Modification, Current Procedural Terminology, Fourth Edition, and Healthcare Common Procedure Coding System codes. A total of 42,565 patients with commercial insurance and 8507 Medicare patients were identified. Their mean age was 54.7 years and 74.8 years, and 48.7% and 46.9% were male, respectively. In total, 66.3% of commercial patients (n = 28,206) were not prescribed any maintenance COPD pharmacotherapy (59.1% no medication; 7.2% inhaled short-acting β2-agonist only). In the Medicare population, 70.9% (n = 6031) were not prescribed any maintenance COPD pharmacotherapy (66.0% no medication; 4.9% short-acting β2-agonist only). A subset of patients classified as high-complexity were similarly undertreated, with 58.7% (5358/9121) of commercial and 68.8% (1616/2350) of Medicare patients not prescribed maintenance COPD pharmacotherapy. Only 18.0% and 9.8% of diagnosed smokers in the commercial and Medicare cohorts had a claim for a smoking cessation intervention and just 16.6% and 23.5%, respectively, had claims for an influenza vaccination. This study highlights a high degree of undertreatment of COPD in both commercial and Medicare patients, with most patients receiving no maintenance pharmacotherapy or influenza vaccination.

Digital monitoring and care: Virtual medicine.

PubMed

Shinbane, Jerold S; Saxon, Leslie A

2016-11-01

Remote digital health monitoring technologies can be synergistically organized to create a virtual medical system providing more continuous care centered on the patient rather than the bricks and mortar medical complex. Utilization of the digitalized patient health monitoring can facilitate diagnosis, treatment plans, physician-patient interaction, and accelerate the progress of medical research, education, and training. The field of cardiac electrophysiology has been an early adopter of this shift in care and serves as a paradigm applicable to all areas of medicine. The overall impact of this remote virtual care model on the quality of medical care and patient experience requires greater study, as well as vigilance as to the differences between technology and care in order to preserve the intangible and immeasurable factors that bring humanity to the art and science of medicine. Copyright © 2016 Elsevier Inc. All rights reserved.

A critical pathway for the frail elderly cardiac patient.

PubMed

Wit, Mirjam; Schaap, Annet; Umans, Victor

2011-12-01

The medical community needs to better respond to the predictable complexities associated with admission of frail and elderly cardiac patients who may need specific attention and care programs. The nurse practitioner can play an important role to continue and coordinate nursing and medical care. We propose a new critical pathway designed to improve cardiac and nursing care for frail elderly cardiac patients admitted with heart failure or atrial fibrillation. The critical pathway is developed by the nurse practitioner who will act as a pathway coordinator and take care of the medical care of these patients in a teaching hospital setting. This critical pathway is applied to all patients aged >75 years who are admitted for heart failure or atrial fibrillation. The pathway implementation identified 5 important socio-medical parameters that may account for a delayed length of stay, even in patients without a complicated medical situation: delirium and fall prevention, nutritional awareness, fluid restriction efforts, and information optimization of patients and spouses. We developed a critical care pathway for the frail elderly patients who are admitted for heart failure or atrial fibrillation. In doing so, we have been able to change the medical and social management of these patients at a general cardiology ward in a teaching hospital.

Medical Problem-Solving: A Critique of the Literature.

ERIC Educational Resources Information Center

McGuire, Christine H.

1985-01-01

Prescriptive, decision-analysis of medical problem-solving has been based on decision theory that involves calculation and manipulation of complex probability and utility values to arrive at optimal decisions that will maximize patient benefits. The studies offer a methodology for improving clinical judgment. (Author/MLW)

Prevalence, predictors, and clinical consequences of medical adherence in IBD: How to improve it?

PubMed Central

Lakatos, Peter Laszlo

2009-01-01

Inflammatory bowel diseases (IBD) are chronic diseases with a relapsing-remitting disease course necessitating lifelong treatment. However, non-adherence has been reported in over 40% of patients, especially those in remission taking maintenance therapies for IBD. The economical impact of non-adherence to medical therapy including absenteeism, hospitalization risk, and the health care costs in chronic conditions, is enormous. The causes of medication non-adherence are complex, where the patient-doctor relationship, treatment regimen, and other disease-related factors play key roles. Moreover, subjective assessment might underestimate adherence. Poor adherence may result in more frequent relapses, a disabling disease course, in ulcerative colitis, and an increased risk for colorectal cancer. Improving medication adherence in patients is an important challenge for physicians. Understanding the different patient types, the reasons given by patients for non-adherence, simpler and more convenient dosage regimens, dynamic communication within the health care team, a self-management package incorporating enhanced patient education and physician-patient interaction, and identifying the predictors of non-adherence will help devise suitable plans to optimize patient adherence. This editorial summarizes the available literature on frequency, predictors, clinical consequences, and strategies for improving medical adherence in patients with IBD. PMID:19750566

Prevalence, predictors, and clinical consequences of medical adherence in IBD: how to improve it?

PubMed

Lakatos, Peter Laszlo

2009-09-14

Inflammatory bowel diseases (IBD) are chronic diseases with a relapsing-remitting disease course necessitating lifelong treatment. However, non-adherence has been reported in over 40% of patients, especially those in remission taking maintenance therapies for IBD. The economical impact of non-adherence to medical therapy including absenteeism, hospitalization risk, and the health care costs in chronic conditions, is enormous. The causes of medication non-adherence are complex, where the patient-doctor relationship, treatment regimen, and other disease-related factors play key roles. Moreover, subjective assessment might underestimate adherence. Poor adherence may result in more frequent relapses, a disabling disease course, in ulcerative colitis, and an increased risk for colorectal cancer. Improving medication adherence in patients is an important challenge for physicians. Understanding the different patient types, the reasons given by patients for non-adherence, simpler and more convenient dosage regimens, dynamic communication within the health care team, a self-management package incorporating enhanced patient education and physician-patient interaction, and identifying the predictors of non-adherence will help devise suitable plans to optimize patient adherence. This editorial summarizes the available literature on frequency, predictors, clinical consequences, and strategies for improving medical adherence in patients with IBD.

Communication challenges in complex medical environments.

PubMed

Lee, Jessica D; Hohler, Anna

2014-06-01

The provision of health care is becoming increasingly complex and can involve multiple providers and care setting transitions, particularly as the population is living longer, and often with chronic disease. The Electronic Health Record (EHR) was intended to provide a comprehensive documentation of a patient's health-related information; however, health care systems often function in isolation with EHRs that are unique only to that system. The EHR may also limit face-to-face communication between treating physicians within the same system. It is only with diligent effort that changes in medical management plans are conveyed among providers. When multiple providers are involved in a patient's care, physician-to-patient communication may also suffer, which can impact patient satisfaction and outcome. This article describes a scenario in which several lapses in communication occurred, and it outlines other common pitfalls while providing possible solutions for improving communication across the health care spectrum.

Holistic medicine not "torture": performing acupuncture in Galway, Ireland.

PubMed

Anderson, Kevin Taylor

2010-07-01

This article examines how the aesthetic design of clinics and interactive discourse and rituals construct the social reality of acupuncture sessions as a form of holistic medical therapy. Verbal and nonverbal interactions create an appealing medical environment but also help prevent the emergence of undesired counter-realities (e.g., pain, biomedical intervention). Based on observations of acupuncture sessions conducted in Galway, Ireland, I illustrate how ambiance and aesthetic elements of clinics create a complex medico-cultural environment that balances oppositional associations (Western/non-Western, exoticism/convention, medical alterity/medical professionalism). Patients interviewed continually referred to acupuncture as a natural and non-invasive form of medical treatment. This suggests that interpersonal discourse and aesthetic design play key roles in how patients define acupuncture treatment, and that these ephemeral agents may also influence how patients come to define efficacy.

Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs: a prospective cohort analysis.

PubMed

Turner-Stokes, Lynne; Bavikatte, Ganesh; Williams, Heather; Bill, Alan; Sephton, Keith

2016-09-08

To evaluate functional outcomes, care needs and cost-efficiency of hyperacute (HA) rehabilitation for a cohort of in-patients with complex neurological disability and unstable medical/surgical conditions. A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2012-2015. Two HA specialist rehabilitation services in England, providing different service models for HA rehabilitation. All patients admitted to each of the units with an admission rehabilitation complexity M score of ≥3 (N=190; mean age 46 (SD16) years; males:females 63:37%). Diagnoses were acquired brain injury (n=166; 87%), spinal cord injury (n=9; 5%), peripheral neurological conditions (n=9; 5%) and other (n=6; 3%). Specialist in-patient multidisciplinary rehabilitation combined with management and stabilisation of intercurrent medical and surgical problems. Rehabilitation complexity and medical acuity: Rehabilitation Complexity Scale-version 13. Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK FIM+FAM). (1) reduction in dependency and (2) cost-efficiency, measured as the time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of on-going care in the community. The mean length of stay was 103 (SD66) days. Some differences were observed between the two units, which were in keeping with the different service models. However, both units showed a significant reduction in dependency and acuity between admission and discharge on all measures (Wilcoxon: p<0.001). For the 180 (95%) patients with complete NPCNA data, the mean episode cost was £77 119 (bootstrapped 95% CI £70 614 to £83 894) and the mean reduction in 'weekly care costs' was £462/week (95% CI 349 to 582). The mean time to offset the cost of rehabilitation was 27.6 months (95% CI 13.2 to 43.8). Despite its relatively high initial cost, specialist HA rehabilitation can be highly cost-efficient, producing substantial savings in on-going care costs, and relieving pressure in the acute care services. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs: a prospective cohort analysis

PubMed Central

Turner-Stokes, Lynne; Bavikatte, Ganesh; Williams, Heather; Bill, Alan; Sephton, Keith

2016-01-01

Objectives To evaluate functional outcomes, care needs and cost-efficiency of hyperacute (HA) rehabilitation for a cohort of in-patients with complex neurological disability and unstable medical/surgical conditions. Design A multicentre cohort analysis of prospectively collected clinical data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database, 2012–2015. Setting Two HA specialist rehabilitation services in England, providing different service models for HA rehabilitation. Participants All patients admitted to each of the units with an admission rehabilitation complexity M score of ≥3 (N=190; mean age 46 (SD16) years; males:females 63:37%). Diagnoses were acquired brain injury (n=166; 87%), spinal cord injury (n=9; 5%), peripheral neurological conditions (n=9; 5%) and other (n=6; 3%). Intervention Specialist in-patient multidisciplinary rehabilitation combined with management and stabilisation of intercurrent medical and surgical problems. Outcome measures Rehabilitation complexity and medical acuity: Rehabilitation Complexity Scale—version 13. Dependency and care costs: Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA). Functional independence: UK Functional Assessment Measure (UK FIM+FAM). Primary outcomes: (1) reduction in dependency and (2) cost-efficiency, measured as the time taken to offset rehabilitation costs by savings in NPCNA-estimated costs of on-going care in the community. Results The mean length of stay was 103 (SD66) days. Some differences were observed between the two units, which were in keeping with the different service models. However, both units showed a significant reduction in dependency and acuity between admission and discharge on all measures (Wilcoxon: p<0.001). For the 180 (95%) patients with complete NPCNA data, the mean episode cost was £77 119 (bootstrapped 95% CI £70 614 to £83 894) and the mean reduction in ‘weekly care costs’ was £462/week (95% CI 349 to 582). The mean time to offset the cost of rehabilitation was 27.6 months (95% CI 13.2 to 43.8). Conclusions Despite its relatively high initial cost, specialist HA rehabilitation can be highly cost-efficient, producing substantial savings in on-going care costs, and relieving pressure in the acute care services. PMID:27609852

Problems and pitfalls in cardiac drug therapy.

PubMed

Stone, S M; Rai, N; Nei, J

2001-01-01

Medical errors in the care of patients may account for 44,000 to 98,000 deaths per year, and 7,000 deaths per year are attributed to medication errors alone. Increasing awareness among health care providers of potential errors is a critical step toward improving the safety of medical care. Because today's medications are increasingly complex, approved at an accelerated rate, and often have a narrow therapeutic window with only a small margin of safety, patient and provider education is critical in assuring optimal therapeutic outcomes. Providers can use electronic resources such as Web sites to keep informed on drug-drug, drug-food, and drug-nutritional supplements interactions.

A simple and reliable health monitoring system for shoulder health: proposal.

PubMed

Liu, Shuo-Fang; Lee, Yann-Long

2014-02-26

The current health care system is complex and inefficient. A simple and reliable health monitoring system that can help patients perform medical self-diagnosis is seldom readily available. Because the medical system is vast and complex, it has hampered or delayed patients in seeking medical advice or treatment in a timely manner, which may potentially affect the patient's chances of recovery, especially those with severe sicknesses such as cancer, and heart disease. The purpose of this paper is to propose a methodology in designing a simple, low cost, Internet-based health-screening platform. This health-screening platform will enable patients to perform medical self-diagnosis over the Internet. Historical data has shown the importance of early detection to ensure patients receive proper treatment and speedy recovery. The platform is designed with special emphasis on the user interface. Standard Web-based user-interface design is adopted so the user feels ease to operate in a familiar Web environment. In addition, graphics such as charts and graphs are used generously to help users visualize and understand the result of the diagnostic. The system is developed using hypertext preprocessor (PHP) programming language. One important feature of this system platform is that it is built to be a stand-alone platform, which tends to have better user privacy security. The prototype system platform was developed by the National Cheng Kung University Ergonomic and Design Laboratory. The completed prototype of this system platform was submitted to the Taiwan Medical Institute for evaluation. The evaluation of 120 participants showed that this platform system is a highly effective tool in health-screening applications, and has great potential for improving the medical care quality for the general public.

Using Fast Healthcare Interoperability Resources (FHIR) for the Integration of Risk Minimization Systems in Hospitals.

PubMed

Saleh, Kutaiba; Stucke, Stephan; Uciteli, Alexandr; Faulbrück-Röhr, Sebastian; Neumann, Juliane; Tahar, Kais; Ammon, Danny; Schmidt, Tobias; Neumuth, Thomas; Besting, Andreas; Portheine, Frank; Herre, Heinrich; Kaeding, André; Specht, Martin

2017-01-01

With the growing strain of medical staff and complexity of patient care, the risk of medical errors increases. In this work we present the use of Fast Healthcare Interoperability Resources (FHIR) as communication standard for the integration of an ontology- and agent-based system to identify risks across medical processes in a clinical environment.

A Pathophysiological Model-Driven Communication for Dynamic Distributed Medical Best Practice Guidance Systems.

PubMed

Hosseini, Mohammad; Jiang, Yu; Wu, Poliang; Berlin, Richard B; Ren, Shangping; Sha, Lui

2016-11-01

There is a great divide between rural and urban areas, particularly in medical emergency care. Although medical best practice guidelines exist and are in hospital handbooks, they are often lengthy and difficult to apply clinically. The challenges are exaggerated for doctors in rural areas and emergency medical technicians (EMT) during patient transport. In this paper, we propose the concept of distributed executable medical best practice guidance systems to assist adherence to best practice from the time that a patient first presents at a rural hospital, through diagnosis and ambulance transfer to arrival and treatment at a regional tertiary hospital center. We codify complex medical knowledge in the form of simplified distributed executable disease automata, from the thin automata at rural hospitals to the rich automata in the regional center hospitals. However, a main challenge is how to efficiently and safely synchronize distributed best practice models as the communication among medical facilities, devices, and professionals generates a large number of messages. This complex problem of patient diagnosis and transport from rural to center facility is also fraught with many uncertainties and changes resulting in a high degree of dynamism. A critically ill patient's medical conditions can change abruptly in addition to changes in the wireless bandwidth during the ambulance transfer. Such dynamics have yet to be addressed in existing literature on telemedicine. To address this situation, we propose a pathophysiological model-driven message exchange communication architecture that ensures the real-time and dynamic requirements of synchronization among distributed emergency best practice models are met in a reliable and safe manner. Taking the signs, symptoms, and progress of stroke patients transported across a geographically distributed healthcare network as the motivating use case, we implement our communication system and apply it to our developed best practice automata using laboratory simulations. Our proof-of-concept experiments shows there is potential for the use of our system in a wide variety of domains.

Implementation and evaluation of Parkinson disease management in an outpatient clinical pharmacist-run neurology telephone clinic.

PubMed

Stefan, Teodora Cristina; Elharar, Nicole; Garcia, Guadalupe

2018-05-01

Parkinson disease (PD) is a progressive, debilitating neurodegenerative disease that often requires complex pharmacologic treatment regimens. Prior to this clinic, there was no involvement of a clinical pharmacy specialist (CPS) in the outpatient neurology clinic at the West Palm Beach Veterans Affairs Medical Center. This was a prospective, quality-improvement project to develop a clinical pharmacist-run neurology telephone clinic and evaluate pharmacologic and nonpharmacologic interventions in an effort to improve the quality of care for patients with PD. Additionally, the CPS conducted medication education groups to 24 patients with PD and their caregivers, if applicable, at this medical center with the purpose of promoting patient knowledge and medication awareness. Medication management was performed via telephone rather than face to face. Only patients with a concomitant mental health diagnosis for which they were receiving at least one psychotropic medication were included for individual visits due to the established scope of practice of the CPS being limited to mental health and primary care medications. Data collection included patient and clinic demographics as well as pharmacologic and nonpharmacologic interventions made for patients enrolled from January 6, 2017, through March 31, 2017. A total of 49 pharmacologic and nonpharmacologic interventions were made for 10 patients. We successfully implemented and evaluated a clinical pharmacist-run neurology telephone clinic for patients with PD. Expansion of this clinic to patients with various neurological disorders may improve access to care using an innovative method of medication management expertise by a CPS.

The new medical-industrial complex.

PubMed

Relman, A S

1980-10-23

The most important health-care development of the day is the recent, relatively unheralded rise of a huge new industry that supplies health-care services for profit. Proprietary hospitals and nursing homes, diagnostic laboratories, home-care and emergency-room services, hemodialysis, and a wide variety of other services produced a gross income to this industry last year of about $35 billion to +40 billion. This new "medical-industrial complex" may be more efficient than its nonprofit competition, but it creates the problems of overuse and fragmentation of services, overemphasis on technology, and "cream-skimming," and it may also exercise undue influence on national health policy. In this medical market, physicians must act as discerning purchasing agents for their patients and therefore should have no conflicting financial interests. Closer attention from the public and the profession, and careful study, are necessary to ensure that the "medical-industrial complex" puts the interest of the public before those of its stockholders.

Medical economic impact of tracheotomy patients on a hospital system.

PubMed

Altman, Kenneth W; Banoff, Karen Merl; Tong, Charles C L

2015-04-01

Tracheotomy patients are a small portion of hospitalizations, but account for disproportionately high risk and costs. There are many complex decisions that go into the care of these patients, and practice variation is expected to be compounded in a health system. This study sought to characterize the medical economic impact of tracheotomy patients on the hospital system. A retrospective review of the health system's hospital billing software was performed for 2013, and pertinent outcomes measures were tabulated. There were 829 tracheotomies performed in the health system of seven hospitals, with total costs of $128,883,865. Average length of stay was 36.74 days for principal procedures, and 43.36 days for tracheotomy as secondary procedures. Mortality was ∼ 18% overall, and re-admissions were 10.93% for primary, and 14.36% for secondary procedures. A fairly wide variation in each category among the different hospitals was observed. There are potentially many factors that impact variations of care and outcomes in patients with tracheotomy. Due to their large economic impact and risks for morbidity and mortality, a formalized care pathway is warranted. Goals of the pathway should include understanding medical decisions surrounding these complex patients, monitoring pertinent outcomes, reducing practice variation, and improving the efficiency of compassionate care.

Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel.

PubMed

Sinnott, Carol; Mercer, Stewart W; Payne, Rupert A; Duerden, Martin; Bradley, Colin P; Byrne, Molly

2015-09-24

Multimorbidity, the presence of two or more chronic conditions, affects over 60 % of patients in primary care. Due to its association with polypharmacy, the development of interventions to optimise medication management in patients with multimorbidity is a priority. The Behaviour Change Wheel is a new approach for applying behavioural theory to intervention development. Here, we describe how we have used results from a review of previous research, original research of our own and the Behaviour Change Wheel to develop an intervention to improve medication management in multimorbidity by general practitioners (GPs), within the overarching UK Medical Research Council guidance on complex interventions. Following the steps of the Behaviour Change Wheel, we sought behaviours associated with medication management in multimorbidity by conducting a systematic review and qualitative study with GPs. From the modifiable GP behaviours identified, we selected one and conducted a focused behavioural analysis to explain why GPs were or were not engaging in this behaviour. We used the behavioural analysis to determine the intervention functions, behavioural change techniques and implementation plan most likely to effect behavioural change. We identified numerous modifiable GP behaviours in the systematic review and qualitative study, from which active medication review (rather than passive maintaining the status quo) was chosen as the target behaviour. Behavioural analysis revealed GPs' capabilities, opportunities and motivations relating to active medication review. We combined the three intervention functions deemed most likely to effect behavioural change (enablement, environmental restructuring and incentivisation) to form the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention. MY COMRADE primarily involves the technique of social support: two GPs review the medications prescribed to a complex multimorbid patient together. Four other behavioural change techniques are incorporated: restructuring the social environment, prompts/cues, action planning and self-incentives. This study is the first to use the Behaviour Change Wheel to develop an intervention targeting multimorbidity and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the MY COMRADE intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work.

Cognitive analyses of a paper medical record and electronic medical record on the documentation of two nursing tasks: patient education and adherence assessment of insulin administration.

PubMed Central

Rinkus, Susan M.; Chitwood, Ainsley

2002-01-01

The incorporation of electronic medical records into busy physician clinics has been a major development in the healthcare industry over the past decade. Documentation of key nursing activities, especially when interacting with patients who have chronic diseases, is often lacking or missing from the paper medical record. A case study of a patient with diabetes mellitus was created. Well established methods for the assessment of usability in the areas of human-computer interaction and computer supported cooperative work were employed to compare the nursing documentation of two tasks in a commercially available electronic medical record (eRecord) and in a paper medical record. Overall, the eRecord was found to improve the timeliness and quality of nursing documentation. With certain tasks, the number of steps to accomplish the same task was higher, which may result in the perception by the end user that the tool is more complex and therefore difficult to use. Recommendations for the eRecord were made to expand the documentation of patient teaching and adherence assessment and to incorporate web technology for patient access to medical records and healthcare information. PMID:12463905

Providing emergency medical care to offshore oil and gas platforms in the Gulf of Mexico using telemedicine

NASA Astrophysics Data System (ADS)

Bouabene, Anis

2002-08-01

UTMB is developing with industrial partners the "24/7 telemedicine triage project" to provide emergency medical care to offshore oil and gas rigs and platforms in the Gulf of Mexico. The oil and gas industry is second only to the US department of defense in the number of employees stationed in remote areas. Providing medical care to such populations is logistically complex and expensive. In addition, emergency evacuation is often time-consuming and poses risks for both patients and medical crews. By utilizing high-resolution videoconferencing technology, through a satellite communication, patient visits will be conducted in real time and will provide more informed decisions about the need for more extensive treatment, thereby reducing unnecessary evacuations. In addition, patients who require evacuation will receive a higher standard of care while waiting for transport to a medical facility. UTMB physicians report that 39% of all patients from offshore facilities treated in the emergency department, could have been successfully treated through telemedicine without being evacuated to a hospital. The telemedicine project will employ standard procedures for medical triage, in which patients are directed to appropriate medical experts based on their symptoms or type of injury.

Real-world health outcomes in adults with moderate-to-severe psoriasis in the United States: a population study using electronic health records to examine patient-perceived treatment effectiveness, medication use, and healthcare resource utilization.

PubMed

Armstrong, April W; Foster, Shonda A; Comer, Brian S; Lin, Chen-Yen; Malatestinic, William; Burge, Russel; Goldblum, Orin

2018-06-28

Little is known regarding real-world health outcomes data among US psoriasis patients, but electronic health records (EHR) that collect structured data at point-of-care may provide opportunities to investigate real-world health outcomes among psoriasis patients. Our objective was to investigate patient-perceived treatment effectiveness, patterns of medication use (duration, switching, and/or discontinuation), healthcare resource utilization, and medication costs using real-world data from psoriasis patients. Data for adults (≥18-years) with a dermatology provider-given diagnosis of psoriasis from 9/2014-9/2015 were obtained from dermatology practices using a widely used US dermatology-specific EHR containing over 500,000 psoriasis patients. Disease severity was captured by static physician's global assessment and body surface area. Patient-perceived treatment effectiveness was assessed by a pre-defined question. Treatment switching and duration were documented. Reasons for discontinuations were assessed using pre-defined selections. Healthcare resource utilization was defined by visit frequency and complexity. From 82,621 patients with psoriasis during the study period, patient-perceived treatment effectiveness was investigated in 2200 patients. The proportion of patients reporting "strongly agree" when asked if their treatment was effective was highest for biologics (73%) and those reporting treatment adherence (55%). In 16,000 patients who received oral systemics and 21,087 patients who received biologics, median treatment duration was longer for those who received biologics (160 vs. 113 days, respectively). Treatment switching was less frequent among patients on systemic monotherapies compared to those on combination therapies. The most common reason for discontinuing biologics was loss of efficacy; the most common reason for discontinuing orals was side effects. In 28,754 patients, higher disease severity was associated with increased healthcare resource utilization (increased visit frequency and complexity). When compared between treatment groups (n = 10,454), healthcare resource utilization was highest for phototherapy. Annual medication costs were higher for biologics ($21,977) than oral systemics ($3413). Real-world research using a widely implemented dermatology EHR provided valuable insights on patient perceived treatment effectiveness, patterns of medication usage, healthcare resource utilization, and medication costs for psoriasis patients in the US. This study and others utilizing EHRs for real-world research may assist clinical and payer decisions regarding the management of psoriasis.

[Application of nootropic agents in complex treatment of patients with concussion of the brain].

PubMed

Tkachev, A V

2007-01-01

65 patients with a mild craniocereberal trauma have been observed. Medical examination included among general clinical methods the following methods: KT (MRT) of the brain, oculist examination including the observation of eye fundus. For objectification of a patient' complaints the authors used orientation and Galvestona's amnesia tests, feeling scale (psychological test), the table to determine the level of memory. Tests have been carried out on the first, tenth and thirty day of the treatment. Patients of the first group received in a complex treatment -pramistar, patients of the second group - piracetam. Patients of both groups noted considerable improvement during a complex treatment (disappearance of headache, dizziness and nausea) and at the same time patients receiving pramistar had better restoration of orientation and feeling. Pramistar was also more effective in patients with amnesia.

A Grounded Investigation of Genred Guidelines in Cancer Care Deliberations

ERIC Educational Resources Information Center

Teston, Christa B.

2009-01-01

Genred documents facilitate collaboration and workplace practices in many ways--particularly in the medical workplace. This article represents a portion of a larger grounded investigation of how medical professionals invoke a wide range of rhetorical strategies when deliberating about complex patient cases during weekly, multidisciplinary…

UK medical tourists in Thailand: they are not who you think they are.

PubMed

Noree, Thinakorn; Hanefeld, Johanna; Smith, Richard

2014-05-06

Travel for medical treatment is an aspect of globalization and health that is comparatively less understood. Little is known about volume, characteristic and motivation of medical tourists, limiting understanding of effects on health systems and patients. Thailand is amongst a handful of countries that have positioned themselves as medical tourism destination. This paper examines in unprecedented detail volume and characteristics of medical tourists who travel from the UK to Thailand for treatment. As part of a wider medical tourism study, authors gained access to over 4000 patient records from the five largest private hospitals in Thailand. These included information on country of origin, gender, age, arrival month, hospitalization, diagnosis, procedures, length of stay, medical expenditure and type of payment. Patient records were analysed to understand who travels and findings were triangulated with data from the UK International Passenger Survey (IPS). 104,830 medical tourists visited these hospitals in Thailand in 2010. While patients originate all over the world, UK medical tourists represent the largest group amongst Europeans. The majority UK medical tourists (60%) have comparatively small, elective procedures, costing less than USD 500. A significant minority of patients travel for more serious orthopedic and cardiothoracic procedures. Data of individual patient records from Thailand shows a higher number of UK patients traveled to Thailand than indicated by the IPS. Thailand is attracting a large number of medical tourists including larger numbers of UK patients than previously estimated. However, as many patients travel for comparatively minor procedures treatment may not be their primary motivation for travel. The small but significant proportion of older UK residents traveling for complex procedures may point to challenges within the NHS.

UK medical tourists in Thailand: they are not who you think they are

PubMed Central

2014-01-01

Background Travel for medical treatment is an aspect of globalization and health that is comparatively less understood. Little is known about volume, characteristic and motivation of medical tourists, limiting understanding of effects on health systems and patients. Thailand is amongst a handful of countries that have positioned themselves as medical tourism destination. This paper examines in unprecedented detail volume and characteristics of medical tourists who travel from the UK to Thailand for treatment. Methods As part of a wider medical tourism study, authors gained access to over 4000 patient records from the five largest private hospitals in Thailand. These included information on country of origin, gender, age, arrival month, hospitalization, diagnosis, procedures, length of stay, medical expenditure and type of payment. Patient records were analysed to understand who travels and findings were triangulated with data from the UK International Passenger Survey (IPS). Results 104,830 medical tourists visited these hospitals in Thailand in 2010. While patients originate all over the world, UK medical tourists represent the largest group amongst Europeans. The majority UK medical tourists (60%) have comparatively small, elective procedures, costing less than USD 500. A significant minority of patients travel for more serious orthopedic and cardiothoracic procedures. Data of individual patient records from Thailand shows a higher number of UK patients traveled to Thailand than indicated by the IPS. Conclusions Thailand is attracting a large number of medical tourists including larger numbers of UK patients than previously estimated. However, as many patients travel for comparatively minor procedures treatment may not be their primary motivation for travel. The small but significant proportion of older UK residents traveling for complex procedures may point to challenges within the NHS. PMID:24885204

Awareness and knowledge among internal medicine house-staff for dose adjustment of commonly used medications in patients with CKD.

PubMed

Surana, Sikander; Kumar, Neeru; Vasudeva, Amita; Shaikh, Gulvahid; Jhaveri, Kenar D; Shah, Hitesh; Malieckal, Deepa; Fogel, Joshua; Sidhu, Gurwinder; Rubinstein, Sofia

2017-01-17

Drug dosing errors result in adverse patient outcomes and are more common in patients with chronic kidney disease (CKD). As internists treat the majority of patients with CKD, we study if Internal Medicine house-staff have awareness and knowledge about the correct dosage of commonly used medications for those with CKD. A cross-sectional survey was performed and included 341 participants. The outcomes were the awareness of whether a medication needs dose adjustment in patients with CKD and whether there was knowledge for the level of glomerular filtration rate (GFR) a medication needs to be adjusted. The overall pattern for all post-graduate year (PGY) groups in all medication classes was a lack of awareness and knowledge. For awareness, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, endocrine, gastrointestinal, and rheumatologic medication classes but not for analgesic, cardiovascular, and neuropsychotropic medication classes. For knowledge, there were statistically significant increased mean differences for PGY2 and PGY3 as compared to PGY1 for allergy, cardiovascular, endocrine, and gastrointestinal, medication classes but not for analgesic, neuropsychotropic, and rheumatologic medication classes. Internal Medicine house-staff across all levels of training demonstrated poor awareness and knowledge for many medication classes in CKD patients. Internal Medicine house-staff should receive more nephrology exposure and formal didactic educational training during residency to better manage complex treatment regimens and prevent medication dosing errors.

Impact of Pharmacist-Conducted Comprehensive Medication Reviews for Older Adult Patients to Reduce Medication Related Problems.

PubMed

Kiel, Whitney J; Phillips, Shaun W

2017-12-31

Older adults are demanding increased healthcare attention with regards to prescription use due in large part to highly complex medication regimens. As patients age, medications often have a more pronounced effect on older adults, negatively impacting patient safety and increasing healthcare costs. Comprehensive medication reviews (CMRs) optimize medications for elderly patients and help to avoid inappropriate medication use. Previous literature has shown that such CMRs can successfully identify and reduce the number of medication-related problems and improve acute healthcare utilization. The purpose of this pharmacy resident research study is to examine the impact of pharmacist-conducted geriatric medication reviews to reduce medication-related problems within a leading community health system in southwest Michigan. Furthermore, the study examines type of pharmacist interventions made during medication reviews, acute healthcare utilization, and physician assessment of the pharmacist's value. The study was conducted as a retrospective post-hoc analysis on ambulatory patients who received a CMR by a pharmacist at a primary care practice. Inclusion criteria included patients over 65 years of age with concurrent use of at least five medications who were a recent recipient of a CMR. Exclusion criteria included patients with renal failure, or those with multiple providers involved in primary care. The primary outcome was the difference in number of medication-related problems, as defined by the START and STOPP Criteria (Screening Tool to Alert doctors to Right Treatment/Screening Tool of Older Persons' Prescriptions). Secondary outcomes included hospitalizations, emergency department visits, number and type of pharmacist interventions, acceptance rate of pharmacist recommendations, and assessment of the pharmacist's value by clinic providers. There were a total of 26 patients that received a comprehensive medication review from the pharmacist and were compared to a control group, patients that did not receive a CMR. The average patient age for both groups was 76 years old. A total of 11 medication-related problems in the intervention group patients were identified compared with 24 medication-related problems in the control group ( p -value 0.002). Pharmacist-led comprehensive medication reviews were associated with a statistically significant different in the number of medication-related problems as defined by the START and STOPP criteria.

Scedosporium apiospermum complex in cystic fibrosis; should we treat?

PubMed

Noni, Maria; Katelari, Anna; Kapi, Aikaterini; Stathi, Angeliki; Dimopoulos, George; Doudounakis, Stavros-Eleftherios

2017-09-01

Species of the Scedosporium apiospermum complex are the second most frequent filamentous fungi after Aspergillus fumigatus that can be found in cystic fibrosis (CF). Mixed colonisation by S. apiospermum complex and A. fumigatus is also quite common. In this study we summarise all CF patients who were colonised by S. apiospermum complex during their childhood and we present two CF patients who were treated as fungal bronchitis due to S. apiospermum complex. The medical records of 400 CF patients were reviewed in order to identify those with positive respiratory cultures for S. apiospermum complex. Scedosporium apiospermum complex was isolated in 10 CF patients and six of them had more than two positive sputum cultures during the study period. By the time of first isolation, the median age was 14.5 years, the median BMI was 19.41 kg/m 2 , the median predicted FEV 1 % was 78.65% and six patients had a history of A. fumigatus isolation. Two patients presented symptoms of infection while they were colonised by S. apiospermum complex. A rapid remission of their symptoms was observed only when antifungal therapy was administered. Antifungal treatment should be considered in CF patients who present symptoms of infection not responding to antibacterial therapy and S. apiospermum complex is persistently growing in sputum cultures. © 2017 Blackwell Verlag GmbH.

Implementation of a Transdisciplinary Team for the Transition Support of Medically and Socially Complex Youth.

PubMed

Ciccarelli, Mary R; Gladstone, Erin B; Armstrong Richardson, Eprise A J

2015-01-01

This article reports the ongoing work of a statewide transition support program which serves youth ages 11 to 22 with medically complex conditions and socially complex lives. Seven years of transition support services have led to program evolution demonstrated via a descriptive summary of the patients along with both families' and primary care providers' responses to satisfaction surveys. An illustrative case is used to highlight the types of expertise needed in specialized transition service delivery for patients with significant complexity. The team's analysis of their transdisciplinary work processes further explains the work. Nearly three hundred youth with complex needs are served yearly. Families and primary care providers express high satisfaction with the support of the services. The case example shows the broad array of transition-specific services engaged beyond the usual skill set of pediatric or adult care coordination teams. Transdisciplinary team uses skills in collaboration, support, learning, and compromise within a trusting and respectful environment. They describe the shared responsibility and continuous learning of the whole team. Youth with complex medical conditions and complex social situations are at higher risk for problems during transition. Serving this population with a transdisciplinary model is time consuming and requires advanced expertise but, with those investments, we can meet the expectations of the youth, their families and primary care providers. Successful transdisciplinary teamwork requires sustained and focused investment. Further work is needed to describe the complexity of this service delivery along with distinct transition outcomes and costs comparisons. Copyright © 2015 Elsevier Inc. All rights reserved.

The emergency patient's participation in medical decision-making.

PubMed

Wang, Li-Hsiang; Goopy, Suzanne; Lin, Chun-Chih; Barnard, Alan; Han, Chin-Yen; Liu, Hsueh-Erh

2016-09-01

The purpose of this research was to explore the medical decision-making processes of patients in emergency departments. Studies indicate that patients should be given enough time to acquire relevant information and receive adequate support when they need to make medical decisions. It is difficult to satisfy these requirements in emergency situations. Limited research has addressed the topic of decision-making among emergency patients. This qualitative study used a broadly defined grounded theory approach to explore decision-making in an emergency department in Taiwan. Thirty emergency patients were recruited between June and December 2011 for semi-structured interviews that were audio-taped and transcribed verbatim. The study identified three stages in medical decision-making by emergency patients: predecision (interpreting the problem); decision (a balancing act) and postdecision (reclaiming the self). Transference was identified as the core category and pattern of behaviour through which patients resolved their main concerns. This transference around decision-making represents a type of bricolage. The findings fill a gap in knowledge about the decision-making process among emergency patients. The results inform emergency professionals seeking to support patients faced with complex medical decision-making and suggest an emphasis on informed patient decision-making, advocacy, patient-centred care and in-service education of health staff. © 2016 John Wiley & Sons Ltd.

Development of an interface-focused educational complex intervention.

PubMed

Sampson, Rod; MacVicar, Ronald; Wilson, Philip

2017-09-01

In many countries, the medical primary-secondary care interface is central to the delivery of quality patient care. There is prevailing interest in developing initiatives to improve interface working for the benefit of health care professionals and their patients. To describe the development of an educational intervention designed to improve working at the primary-secondary care interface in NHS Scotland (United Kingdom) within the context of the Medical Research Council framework for the development and evaluation of complex interventions. A primary-secondary care interface focused Practice-based Small Group Learning (PBSGL) module was developed building upon qualitative synthesis and original research. A 'meeting of experts' shaped the module, which was subsequently piloted with a group of interface clinicians. Reflections on the module were sought from clinicians across NHS Scotland to provide contextual information from other areas. The PBSGL approach can be usefully applied to the development of a primary-secondary care interface-focused medical educational intervention.

Diagnosis and management of patients with hypercalcaemia.

PubMed

Walker, Jennie

2015-05-01

Hypercalcaemia is a common biochemical abnormality in the blood that can be caused by malignancy, hyperparathyroidism, medications or underlying medical conditions. Initial signs and symptoms are often vague, however, if someone has severe hypercalcaemia it is treated as an emergency, requiring prompt management to prevent life-threatening complications such as dehydration, cardiac arrhythmias or coma. Understanding the pathophysiology, signs and symptoms of hypercalcaemia enables effective diagnosis and holistic management of the patient with complex health needs.

Medication Adherence: WHO Cares?

PubMed Central

Brown, Marie T.; Bussell, Jennifer K.

2011-01-01

The treatment of chronic illnesses commonly includes the long-term use of pharmacotherapy. Although these medications are effective in combating disease, their full benefits are often not realized because approximately 50% of patients do not take their medications as prescribed. Factors contributing to poor medication adherence are myriad and include those that are related to patients (eg, suboptimal health literacy and lack of involvement in the treatment decision–making process), those that are related to physicians (eg, prescription of complex drug regimens, communication barriers, ineffective communication of information about adverse effects, and provision of care by multiple physicians), and those that are related to health care systems (eg, office visit time limitations, limited access to care, and lack of health information technology). Because barriers to medication adherence are complex and varied, solutions to improve adherence must be multifactorial. To assess general aspects of medication adherence using cardiovascular disease as an example, a MEDLINE-based literature search (January 1, 1990, through March 31, 2010) was conducted using the following search terms: cardiovascular disease, health literacy, medication adherence, and pharmacotherapy. Manual sorting of the 405 retrieved articles to exclude those that did not address cardiovascular disease, medication adherence, or health literacy in the abstract yielded 127 articles for review. Additional references were obtained from citations within the retrieved articles. This review surveys the findings of the identified articles and presents various strategies and resources for improving medication adherence. PMID:21389250

A Comprehensive Look at Polypharmacy and Medication Screening Tools for the Older Cancer Patient

PubMed Central

DeGregory, Kathlene A.; Morris, Amy L.; Ramsdale, Erika E.

2016-01-01

Inappropriate medication use and polypharmacy are extremely common among older adults. Numerous studies have discussed the importance of a comprehensive medication assessment in the general geriatric population. However, only a handful of studies have evaluated inappropriate medication use in the geriatric oncology patient. Almost a dozen medication screening tools exist for the older adult. Each available tool has the potential to improve aspects of the care of older cancer patients, but no single tool has been developed for this population. We extensively reviewed the literature (MEDLINE, PubMed) to evaluate and summarize the most relevant medication screening tools for older patients with cancer. Findings of this review support the use of several screening tools concurrently for the elderly patient with cancer. A deprescribing tool should be developed and included in a comprehensive geriatric oncology assessment. Finally, prospective studies are needed to evaluate such a tool to determine its feasibility and impact in older patients with cancer. Implications for Practice: The prevalence of polypharmacy increases with advancing age. Older adults are more susceptible to adverse effects of medications. “Prescribing cascades” are common, whereas “deprescribing” remains uncommon; thus, older patients tend to accumulate medications over time. Older patients with cancer are at high risk for adverse drug events, in part because of the complexity and intensity of cancer treatment. Additionally, a cancer diagnosis often alters assessments of life expectancy, clinical status, and competing risk. Screening for polypharmacy and potentially inappropriate medications could reduce the risk for adverse drug events, enhance quality of life, and reduce health care spending for older cancer patients. PMID:27151653

Virtual Patients in Geriatric Education

ERIC Educational Resources Information Center

Tan, Zaldy S.; Mulhausen, Paul L.; Smith, Stephen R.; Ruiz, Jorge G.

2010-01-01

The virtual patient is a case-based computer program that combines textual information with multimedia elements such as audio, graphics, and animation. It is increasingly being utilized as a teaching modality by medical educators in various fields of instruction. The inherent complexity of older patients and the shortage of geriatrics educators…

The patient-surgeon relationship in the cyber era: communication and information.

PubMed

Blake, J Herman; Schwemmer, Mary Kay; Sade, Robert M

2012-11-01

From Laennec's invention of the stethoscope in 1816 to the recently introduced Sapien transcatheter aortic valve replacement, the increasing complexity of health care technology has altered the relationship between patients and physicians, usually for the better. Telemedicine, the provision of medical services through electronic media, has dramatically changed how the patient and physician interact and how medical care is delivered. Many studies of physicians' perceptions of electronic communication with patients have documented recognition of benefits as well as a consistent chorus of concerns about confidentiality, increased workload, inappropriate use, and medicolegal issues. Copyright © 2012 Elsevier Inc. All rights reserved.

[Patient-centred prescription model to improve adequate prescription and therapeutic adherence in patients with multiple disorders].

PubMed

Espaulella-Panicot, Joan; Molist-Brunet, Núria; Sevilla-Sánchez, Daniel; González-Bueno, Javier; Amblàs-Novellas, Jordi; Solà-Bonada, Núria; Codina-Jané, Carles

Patients with multiple disorders and on multiple medication are often associated with clinical complexity, defined as a situation of uncertainty conditioned by difficulties in establishing a situational diagnosis and decision-making. The patient-centred care approach in this population group seems to be one of the best therapeutic options. In this context, the preparation of an individualised therapeutic plan is the most relevant practical element, where the pharmacological plan maintains an important role. There has recently been a significant increase in knowledge in the area of adequacy of prescription and adherence. In this context, we must find a model must be found that incorporates this knowledge into clinical practice by the professionals. Person-centred prescription is a medication review model that includes different strategies in a single intervention. It is performed by a multidisciplinary team, and allows them to adapt the pharmacological plan of patients with clinical complexity. Copyright © 2017 SEGG. Publicado por Elsevier España, S.L.U. All rights reserved.

The challenge of aging and pharmacoterapeutic complexity in the HIV + patient.

PubMed

Morillo-Verdugo, Ramón; Blanco Ramos, José Ramón; Abdel-Kader Martín, Laila; Álvarez de Sotomayor, María

2018-05-01

To describe the current knowledge and management of aging and  pharmacotherapeutic complexity in HIV + patients. A review of literature was carried out, including articles, originals or  reviews, published in English or Spanish, from 2007 to 2017, which analysed the aging and pharmacotherapeutic complexity in HIV + patients. The terms  «Polypharmacy»/»Polypharmacy», «Aging»/»Aging», «Frailty»/»Fragility»,  «Pharmacotherapeutic Complexity»/»Medication Regimen Complexity» and  «HIV»/"HIV» were combined. The review was carried out independently by two  authors. The degree of agreement, according to the Kappa index, was analysed. Results: A total of 208 references were analysed, including, finally, only 68. An  aging of the population and an increase in associated comorbidities have been  identified, especially over 50 years-old. Immunological changes similar to those  that are generated in a non-infected elderly population have been described.  These conditions influencing the prescription of antiretroviral treatment,  according to studies identified. In parallel, polypharmacy is increasingly present,  being defined exclusively by the concomitant use of five drugs.  Pharmacotherapeutic complexity, through the Medication Regimen Complexity  Index, has begun to analyse and relate to health outcomes. There has been a  need to know and apply concepts already known in non-HIV-aged population,  such as de-prescription, potentially inappropriate medication, cholinergic risk, although few results are available. There is a growing interest to know about the relationship between HIV and aging. Pharmacotherapeutic complexity is  beginning to be used as a pharmacotherapeutic follow-up criterion due to its influence on health outcomes. It is necessary to manage and incorporate new  concepts that help pharmacotherapeutic optimization in this population. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

Exploring Factors that Influence Informal Caregiving in Medication Management for Home Hospice Patients

PubMed Central

Berman, Rebecca; Halpern, Leslie; Pickard, A. Simon; Schrauf, Robert; Witt, Whitney

2010-01-01

Abstract Objective To explore factors that influence how informal caregivers manage medications as part of caring for hospice patients. Methods : Semistructured, open-ended interviews were conducted with 23 informal caregivers and 22 hospice providers from 4 hospice programs in the Chicago metropolitan areas. Qualitative analysis was conducted consistent with the grounded theory approach. Results : In general, informal caregivers and hospice providers identified similar key factors that facilitated or impeded caregivers' process in managing medications. Caregivers' life experience and self-confidence were considered assets that facilitated medication management. Limitations impeding the process included caregivers' negative emotional states, cognitive and physical impairments, low literacy, other competing responsibilities, as well as patients' negative emotional states and complex medication needs. Furthermore, the social context of medication management emerged as a salient theme: caregivers' good interpersonal relations with patients facilitated medication management, whereas poor communication/relations among caregivers within a support network impeded the process. While both study groups discussed the positive attributes of good caregiver–patient relations and support from multiple caregivers, hospice providers were cautious about the potential adverse influence of close relations with patients on caregivers' decision making about medications and discussed poor communication/relations among informal and privately hired caregivers that often resulted from family conflicts and/or a lack of long-standing leadership. Conclusion Our findings suggest additional intervention points, beyond knowledge and skill building, that could be addressed to support caregivers in executing medication responsibilities at home for hospice patients. PMID:20836633

Influence of Herbal Complexes Containing Licorice on Potassium Levels: A Retrospective Study

PubMed Central

Jung, WooSang; Kwon, SeungWon; Im, JinWook; Park, SeongUk; Moon, SangKwan; Park, JungMi; Ko, ChangNam; Cho, KiHo

2014-01-01

To observe the influence of these complexes on potassium levels in a clinical setting, we investigated the influence of herbal complexes containing licorice on potassium levels. We retrospectively examined the medical records of patients treated with herbal complexes containing licorice from January 1, 2010, to December 31, 2010. We recorded the changes in the levels of potassium, creatinine, and blood urea nitrogen and examined the differences between before and after herbal complexes intake using a paired t-test. In addition, we investigated the prevalence of hypokalemia among these patients and reviewed such patients. We identified 360 patients who did not show significant changes in the levels of potassium and creatinine (P = 0.815, 0.289). We observed hypokalemia in 6 patients. However, in 5 patients, the hypokalemia did not appear to be related to the licorice. Thus, we could suggest that herbal complexes containing licorice do not significantly influence the potassium levels in routine clinical herbal therapies. However, we propose that follow-up examination for potassium levels is required to prevent any unpredictable side effects of administration of licorice in routine herbal medicine care. PMID:25045393

Concomitant medication of psychoses in a lifetime perspective.

PubMed

Vares, Maria; Saetre, Peter; Strålin, Pontus; Levander, Sten; Lindström, Eva; Jönsson, Erik G

2011-01-01

Patients treated with antipsychotic drugs often receive concomitant psychotropic compounds. Few studies address this issue from a lifetime perspective. Here, an analysis is presented of the prescription pattern of such concomitant medication from the first contact with psychiatry until the last written note in the case history documents, in patients with a diagnosis of psychotic illness. A retrospective descriptive analysis of all case history data of 66 patients diagnosed with schizophrenia or schizophrenia-like psychotic disorders. Benzodiazepines and benzodiazepine-related anxiolytic drugs had been prescribed to 95% of the patients, other anxiolytics, sedatives or hypnotic drugs to 61%, anti-parkinsonism drugs to 86%, and antidepressants to 56% of the patients. However, lifetime doses were small and most of the time patients had no concomitant medication. The prescribed lifetime dose of anti-parkinsonism drugs was associated with that of prescribed first-generation but not second-generation antipsychotics. Most psychosis patients are sometimes treated with concomitant drugs but mainly over short periods. Lifetime concomitant add-on medication at the individual patient level is variable and complex but not extensive. Copyright © 2011 John Wiley & Sons, Ltd.

Patient, Caregiver, and Physician Work in Heart Failure Disease Management: A Qualitative Study of Issues That Undermine Wellness.

PubMed

Farmer, Steven A; Magasi, Susan; Block, Phoebe; Whelen, Megan J; Hansen, Luke O; Bonow, Robert O; Schmidt, Philip; Shah, Ami; Grady, Kathleen L

2016-08-01

To identify factors underlying heart failure hospitalization. Between January 1, 2012, and May 31, 2012, we combined medical record reviews and cross-sectional qualitative interviews of multiple patients with heart failure, their clinicians, and their caregivers from a large academic medical center in the Midwestern United States. The interview data were analyzed using a 3-step grounded theory-informed process and constant comparative methods. Qualitative data were compared and contrasted with results from the medical record review. Patient nonadherence to the care plan was the most important contributor to hospital admission; however, reasons for nonadherence were complex and multifactorial. The data highlight the importance of patient education for the purposes of condition management, timeliness of care, and effective communication between providers and patients. To improve the consistency and quality of care for patients with heart failure, more effective relationships among patients, providers, and caregivers are needed. Providers must be pragmatic when educating patients and their caregivers about heart failure, its treatment, and its prognosis. Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

Cardiac imaging modalities with ionizing radiation: the role of informed consent.

PubMed

Paterick, Timothy E; Jan, M Fuad; Paterick, Zachary R; Tajik, A Jamil; Gerber, Thomas C

2012-06-01

Informed consent ideally results in patient autonomy and rational health care decisions. Frequently, patients face complex medical decisions that require a delicate balancing of anticipated benefits and potential risks, which is the concept of informed consent. This balancing process requires an understanding of available medical evidence and alternative medical options, and input from experienced physicians. The informed consent doctrine places a positive obligation on physicians to partner with patients as they try to make the best decision for their specific medical situation. The high prevalence and mortality related to heart disease in our society has led to increased cardiac imaging with modalities that use ionizing radiation. This paper reviews how physicians can meet the ideals of informed consent when considering cardiac imaging with ionizing radiation, given the limited evidence for risks and benefits. The goal is an informed patient making rational choices based on available medical information. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Post-graduate education for medical specialists focused on patients with medically unexplained physical symptoms; development of a communication skills training programme.

PubMed

Weiland, Anne; Blankenstein, Annette H; Willems, Mariëtte H A; Van Saase, Jan L C M; Van der Molen, Henk T; Van Dulmen, Alexandra M; Arends, Lidia R

2013-09-01

Stepwise description of the development of a post-graduate communication skills training programme for medical specialists focused on patients with medically unexplained physical symptoms (MUPS) to improve specialist interaction with MUPS patients. Using the 'intervention mapping approach' we accomplished a needs assessment (literature study and pilot) to formulate intervention objectives and identify methods and techniques for a MUPS-focused communication skills training programme for medical specialists. A 14-h training programme which consists of experiential learning, role-play and feedback. Using skills from Cognitive Behavioural Therapy, medical specialists are stimulated to explore interrelating factors that reinforce symptoms, to reassure patients effectively and to provide plausible and understandable explanations for MUPS. Dealing with complex referrals and informing GPs properly are also practiced. By applying the 'intervention mapping approach' we were able to create a feasible and promising intervention to improve specialist interaction with MUPS patients. Intervention effects are currently being assessed in a randomized controlled trial. If the RCT demonstrates sufficient effectiveness and efficiency of the MUPS focused communication skills training programme for medical specialists the intervention could be embedded in post-graduate education of medical specialists and residents. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Building health information technology capacity: they may come but will they use it?

PubMed

Burke-Bebee, Suzie; Wilson, Marisa; Buckley, Kathleen M

2012-10-01

Medical errors remain a major safety problem more than a decade after the Institute of Medicine reported 98 000 related deaths occur yearly in US hospitals. Medication errors account for one-third of these errors. Although medication reconciliation is an accepted care standard for patient safety, little evidence is available to make practice recommendations for primary care. The purpose of this study was to evaluate the effectiveness of using secure e-mail alerts within the reconciliation process on patient medication safety in clinics where electronic and personal health records are used. A nonexperimental, descriptive design with a convenience sample of 62 patients from two Veterans Health Administration clinics was used. Patients received secure e-mail instructing them to review their online medication list, update it based on home medications, and bring it to the appointment for discussion with their provider. A retrospective chart review was conducted examining changes made to medication lists in the electronic record after reconciliation. Data revealed the organization's adoption of secure e-mail did not guarantee its meaningful use by providers and patients, a clear barrier to implementing technology as an adjunct to care in context of complex clinical processes such as medication reconciliation. Lessons learned from the project's implementation are discussed.

Geriatrix: A Role-Playing Game.

ERIC Educational Resources Information Center

Hoffman, Stephanie B.; And Others

1985-01-01

To sensitize medical students to the complexities of geriatric patient care, the geriatrics faculty of Upstate Medical Center's Clinical Campus developed Geriatrix, a role-playing game. Students attempt to win points in a board game containing Fact, Concept, and Crisis Squares. Crises promote exposure to ethical dilemmas and invite intense debate…

Potentially harmful side-effects: medically unexplained symptoms, somatization, and the insufficient illness narrative for viewers of mystery diagnosis.

PubMed

Farkas, Carol-Ann

2013-09-01

Illness narrative has often been found to play a positive role in both patients' and providers' efforts to find meaning in the illness experience. However, illness narrative can sometimes become counterproductive, even pathological, particularly in cases of medical mystery--cases wherein biopsychosocial factors blur the distinction between bodily dysfunction and somatizing behavior. In this article, the author draws attention to two examples of medical mystery, the clinical presentation of medically unexplained symptoms, and the popular reality television program Mystery Diagnosis, to demonstrate the potentially harmful effects of illness narrative. The medical mystery's complex narrative structure reflects and tends to reinforce providers' and patients' mistaken assumptions, anxieties, and conflicts in ways which obstruct, rather than facilitate, healing.

Parent Perspective on Care Coordination Services for Their Child with Medical Complexity

PubMed Central

Cady, Rhonda G.; Belew, John L.

2017-01-01

The overarching goal of care coordination is communication and co-management across settings. Children with medical complexity require care from multiple services and providers, and the many benefits of care coordination on health and patient experience outcomes have been documented. Despite these findings, parents still report their greatest challenge is communication gaps. When this occurs, parents assume responsibility for aggregating and sharing health information across providers and settings. A new primary-specialty care coordination partnership model for children with medical complexity works to address these challenges and bridge communication gaps. During the first year of the new partnership, parents participated in focus groups to better understand how they perceive communication and collaboration between the providers and services delivering care for their medically complex child. Our findings from these sessions reflect the current literature and highlight additional challenges of rural families, as seen from the perspective of the parents. We found that parents appreciate when professional care coordination is provided, but this is often the exception and not the norm. Additionally, parents feel that the local health system’s inability to care for their medically complex child results in unnecessary trips to urban-based specialty care. These gaps require a system-level approach to care coordination and, consequently, new paradigms for delivery are urgently needed. PMID:28587274

Parent Perspective on Care Coordination Services for Their Child with Medical Complexity.

PubMed

Cady, Rhonda G; Belew, John L

2017-06-06

The overarching goal of care coordination is communication and co-management across settings. Children with medical complexity require care from multiple services and providers, and the many benefits of care coordination on health and patient experience outcomes have been documented. Despite these findings, parents still report their greatest challenge is communication gaps. When this occurs, parents assume responsibility for aggregating and sharing health information across providers and settings. A new primary-specialty care coordination partnership model for children with medical complexity works to address these challenges and bridge communication gaps. During the first year of the new partnership, parents participated in focus groups to better understand how they perceive communication and collaboration between the providers and services delivering care for their medically complex child. Our findings from these sessions reflect the current literature and highlight additional challenges of rural families, as seen from the perspective of the parents. We found that parents appreciate when professional care coordination is provided, but this is often the exception and not the norm. Additionally, parents feel that the local health system's inability to care for their medically complex child results in unnecessary trips to urban-based specialty care. These gaps require a system-level approach to care coordination and, consequently, new paradigms for delivery are urgently needed.

Psychodynamic concepts inherent in a biopsychosocial model of care of traumatic injuries.

PubMed

Wain, Harold J; Gabriel, Geoffrey M

2007-01-01

The psychological issues facing medical and surgical patients suffering from traumatic injuries are numerous and varied. These injuries may occur in the settings of armed conflict, terrorist attack, natural disaster, or accident. The goal of preventing or decreasing significant and disabling psychiatric comorbidity can be the objective and assignment of a Psychiatry Consultation Liaison Service (PCLS) within the hospital setting. A comprehensive trauma consultation service could be designed to assist the entire medical complex in its response to various events. The needs of the patient, the patient's primary support group, and the medical staff must be considered in the development of a treatment strategy for the setting of a traumatic event. This article describes the integration of a Preventive Medical Psychiatry Service (PMP) at Walter Reed Army Medical Center (WRAMC) into a traditional PCLS. The PMP model is built upon the biopsychosocial model and psychodynamic developmental concepts.

[Complexity of care and organizational effectiveness: a survey among medical care units in nine Lombardy region hospitals].

PubMed

Pasquali, Sara; Capitoni, Enrica; Tiraboschi, Giuseppina; Alborghetti, Adriana; De Luca, Giuseppe; Di Mauro, Stefania

2017-01-01

Eleven medical care units of nine Lombardy Region hospitals organized by levels of care model or by the traditional departmental model have been analyzed, in order to evaluate if methods for complexity of patient-care evaluation represent an index factor of nursing organizational effectiveness. Survey with nine Nurses in managerial position was conducted between Nov. 2013-Jan. 2014. The following factors have been described: context and nursing care model, staffing, complexity evaluation, patient satisfaction, staff well-being. Data were processed through Microsoft Excel. Among Units analysed ,all Units in levels of care and one organized by the departmental model systematically evaluate nursing complexity. Registered Nurses (RN) and Health Care Assistants (HCA) are on average numerically higher in Units that measure complexity (0.55/ 0.49 RN, 0.38/0.23 HCA - ratio per bed). Adopted measures in relation to changes in complexity are:rewarding systems, supporting interventions, such as moving personnel within different Units or additional required working hours; reduction in number of beds is adopted when no other solution is available. Patient satisfaction is evaluated through Customer Satisfaction questionnaires. Turnover, stress and rate of absenteeism data are not available in all Units. Complexity evaluation through appropriate methods is carried out in all hospitals organized in levels of care with personalized nursing care models, though complexity is detected with different methods. No significant differences in applied managerial strategies are present. Patient's satisfaction is evaluated everywhere. Data on staffing wellbeing is scarcely available. Coordinated regional actions are recommended in order to gather comparable data for research, improve decision making and effectiveness of Nursing care.

Scoping review of medical assessment units and older people with complex health needs.

PubMed

Rushton, Carole; Crilly, Julia; Adeleye, Adeniyi; Grealish, Laurie; Beylacq, Mandy; Forbes, Mark

2017-03-01

To explore current knowledge of medical assessment units (MAUs) with specific reference to older people with complex needs and to stimulate new topics and questions for future policy, research and practice. A scoping review was conducted using an integrated-latent thematic approach. This review provides a unique perspective on MAUs and older people which is framed using four themes: efficiency, effectiveness, equity and time. Eighteen articles were reviewed. Most (14) articles reported on efficiency and effectiveness while none reported explicitly on equity. Time was identified as a fourth, latent theme within the literature. Findings from this review indicate that future policy, research and practice relating to MAUs should focus on older people with complex needs, patient-centred metrics and those MAU characteristics most likely to deliver positive health outcomes to this particular cohort of patients. © 2016 AJA Inc.

Factors of interpersonal communication and behavioral health on medication self-efficacy and medication adherence.

PubMed

Archiopoli, Ashley; Ginossar, Tamar; Wilcox, Bryan; Avila, Magdalena; Hill, Ricky; Oetzel, John

2016-12-01

Despite devastating effects on health outcomes and disease progression, many people living with HIV (PLWH) are non-adherent to their medications. Medication self-efficacy is a pivotal factor in medication adherence, yet its formation and relationship with other factors are understudied. This study examines a model that considers the role of three communicative factors (patient-provider communication, social support, and social undermining) and two behavioral health factors (depression and alcohol abuse) and medication self-efficacy impacting medication adherence. Methods included a cross-sectional design using a survey questionnaire of 344 PLWH. Findings indicated that 25% of variance in medication adherence can be explained by a mediation model where depression (B = -.18) and provider-patient communication (B = .21) affect medication self-efficacy, which in turn impacts medication adherence (B = .64). Other variables, including demographics, did not add any explanatory power. These findings demonstrate the complex nature of medication adherence and the formation of medication self-efficacy.

The current and future role of the medical oncologist in the professional care for cancer patients: a position paper by the European Society for Medical Oncology (ESMO).

PubMed

Popescu, R A; Schäfer, R; Califano, R; Eckert, R; Coleman, R; Douillard, J-Y; Cervantes, A; Casali, P G; Sessa, C; Van Cutsem, E; de Vries, E; Pavlidis, N; Fumasoli, K; Wörmann, B; Samonigg, H; Cascinu, S; Cruz Hernández, J J; Howard, A J; Ciardiello, F; Stahel, R A; Piccart, M

2014-01-01

The number of cancer patients in Europe is rising and significant advances in basic and applied cancer research are making the provision of optimal care more challenging. The concept of cancer as a systemic, highly heterogeneous and complex disease has increased the awareness that quality cancer care should be provided by a multidisciplinary team (MDT) of highly qualified healthcare professionals. Cancer patients also have the right to benefit from medical progress by receiving optimal treatment from adequately trained and highly skilled medical professionals. Built on the highest standards of professional training and continuing medical education, medical oncology is recognised as an independent medical specialty in many European countries. Medical oncology is a core member of the MDT and offers cancer patients a comprehensive and systemic approach to treatment and care, while ensuring evidence-based, safe and cost-effective use of cancer drugs and preserving the quality of life of cancer patients through the entire 'cancer journey'. Medical oncologists are also engaged in clinical and translational research to promote innovation and new therapies and they contribute to cancer diagnosis, prevention and research, making a difference for patients in a dynamic, stimulating professional environment. Medical oncologists play an important role in shaping the future of healthcare through innovation and are also actively involved at the political level to ensure a maximum contribution of the profession to Society and to tackle future challenges. This position paper summarises the multifarious and vital contributions of medical oncology and medical oncologists to today's and tomorrow's professional cancer care.

Healthcare provider and patient perspectives on diagnostic imaging investigations.

PubMed

Makanjee, Chandra R; Bergh, Anne-Marie; Hoffmann, Willem A

2015-05-20

Much has been written about the patient-centred approach in doctor-patient consultations. Little is known about interactions and communication processes regarding healthcare providers' and patients' perspectives on expectations and experiences of diagnostic imaging investigations within the medical encounter. Patients journey through the health system from the point of referral to the imaging investigation itself and then to the post-imaging consultation. AIM AND SETTING: To explore healthcare provider and patient perspectives on interaction and communication processes during diagnostic imaging investigations as part of their clinical journey through a healthcare complex. A qualitative study was conducted, with two phases of data collection. Twenty-four patients were conveniently selected at a public district hospital complex and were followed throughout their journey in the hospital system, from admission to discharge. The second phase entailed focus group interviews conducted with providers in the district hospital and adjacent academic hospital (medical officers and family physicians, nurses, radiographers, radiology consultants and registrars). Two main themes guided our analysis: (1) provider perspectives; and (2) patient dispositions and reactions. Golden threads that cut across these themes are interactions and communication processes in the context of expectations, experiences of the imaging investigations and the outcomes thereof. Insights from this study provide a better understanding of the complexity of the processes and interactions between providers and patients during the imaging investigations conducted as part of their clinical pathway. The interactions and communication processes are provider-patient centred when a referral for a diagnostic imaging investigation is included.

Audio-visual communication and its use in palliative care.

PubMed

Coyle, Nessa; Khojainova, Natalia; Francavilla, John M; Gonzales, Gilbert R

2002-02-01

The technology of telemedicine has been used for over 20 years, involving different areas of medicine, providing medical care for the geographically isolated patients, and uniting geographically isolated clinicians. Today audio-visual technology may be useful in palliative care for the patients lacking access to medical services due to the medical condition rather than geographic isolation. We report results of a three-month trial of using audio-visual communications as a complementary tool in care for a complex palliative care patient. Benefits of this system to the patient included 1) a daily limited physical examination, 2) screening for a need for a clinical visit or admission, 3) lip reading by the deaf patient, 4) satisfaction by the patient and the caregivers with this form of communication as a complement to telephone communication. A brief overview of the historical prospective on telemedicine and a listing of applied telemedicine programs are provided.

The Ellipta® in asthma and chronic obstructive pulmonary disease: device characteristics and patient acceptability.

PubMed

Jones, Thomas L; Neville, Daniel M; Chauhan, Anoop J

2018-02-01

Asthma and chronic obstructive pulmonary disease are primarily treated with inhaled medication, but delivery of that medication to its site of action is problematic; patients' ability to use inhalers will affect therapeutic response. Multiple inhaler devices are available but they are variably easy to use with consequent effects on compliance, intentional or otherwise. The Ellipta ® device is a novel blister strip dry powder inhaler with medium resistance and a consistent delivered dose across a range of inspiratory flow rates. The Ellipta has proven easy to use and is preferred by patients across several evaluations and compared with other inhaler devices. The Ellipta is used to administer multiple inhaled medications, all in single daily-dose regimens, making it ideal for patients who struggle with complex inhaled therapy regimens.

Managing patients whose family members are physicians.

PubMed

Bramstedt, K A; Popovich, M

2012-01-01

The ethical complexities involving physicians who treat their own family members are well known and it is generally accepted that such practice should not occur. We present three anonymous cases in which patient family members who worked as physicians complicated the medical care of their hospitalized relatives. When a health care worker's family member becomes a hospital patient, the situation can be emotionally charged due to the medical insight the multiple parties have, as well as the desire of relatives to be protective of their family members. Clinician-relatives need to allow the medical team to assume the role of caretaker when their family members are hospitalized. Teams may need to employ limit setting in order to ensure fair and consistent care for all patients on the ward, and to prevent escalation of emotionally charged situations.

Critical elements of culturally competent communication in the medical encounter: a review and model.

PubMed

Teal, Cayla R; Street, Richard L

2009-02-01

Increasing the cultural competence of physicians is one means of responding to demographic changes in the USA, as well as reducing health disparities. However, in spite of the development and implementation of cultural competence training programs, little is known about the ways cultural competence manifests itself in medical encounters. This paper will present a model of culturally competent communication that offers a framework of studying cultural competence 'in action.' First, we describe four critical elements of culturally competent communication in the medical encounter--communication repertoire, situational awareness, adaptability, and knowledge about core cultural issues. We present a model of culturally competent physician communication that integrates existing frameworks for cultural competence in patient care with models of effective patient-centered communication. The culturally competent communication model includes five communication skills that are depicted as elements of a set in which acquisition of more skills corresponds to increasing complexity and culturally competent communication. The culturally competent communication model utilizes each of the four critical elements to fully develop each skill and apply increasingly sophisticated, contextually appropriate communication behaviors to engage with culturally different patients in complex interactions. It is designed to foster maximum physician sensitivity to cultural variation in patients as the foundation of physician-communication competence in interacting with patients.

Science in the service of patients: lessons from the past in the moral battle for the future of medical education.

PubMed

Weisberg, Daniel F

2014-03-01

Medical schools instill a classic moral standoff in which the responsibility for the betterment of the patient stands at odds with the responsibility for the betterment of society. In critical ways, the latter, in the form of a robust research and technology-driven enterprise, has taken precedence over the former, resulting in harm to patients and individual dignity. This tradeoff can be traced to Abraham Flexner, the father of American medical education. In the wake of the Flexner report, American medicine set out on a course of exponential scientific advancement, but the mistreatment of research subjects and the erosion of the doctor-patient relationship in a health care system that is increasingly unaffordable, complex, and impersonal suggest that such progress has come at a price. Recent efforts by medical schools to emphasize humanism in their curricula and admissions processes have shown promise in orienting the values of academic medicine toward the individual patient's well-being.

Comparative effectiveness of a complex Ayurvedic treatment and conventional standard care in osteoarthritis of the knee--study protocol for a randomized controlled trial.

PubMed

Witt, Claudia M; Michalsen, Andreas; Roll, Stephanie; Morandi, Antonio; Gupta, Shivnarain; Rosenberg, Mark; Kronpass, Ludwig; Stapelfeldt, Elmar; Hissar, Syed; Müller, Matthias; Kessler, Christian

2013-05-23

Traditional Indian Ayurvedic medicine uses complex treatment approaches, including manual therapies, lifestyle and nutritional advice, dietary supplements, medication, yoga, and purification techniques. Ayurvedic strategies are often used to treat osteoarthritis (OA) of the knee; however, no systematic data are available on their effectiveness in comparison with standard care. The aim of this study is to evaluate the effectiveness of complex Ayurvedic treatment in comparison with conventional methods of treating OA symptoms in patients with knee osteoarthritis. In a prospective, multicenter, randomized controlled trial, 150 patients between 40 and 70 years, diagnosed with osteoarthritis of the knee, following American College of Rheumatology criteria and an average pain intensity of ≥40 mm on a 100 mm visual analog scale in the affected knee at baseline will be randomized into two groups. In the Ayurveda group, treatment will include tailored combinations of manual treatments, massages, dietary and lifestyle advice, consideration of selected foods, nutritional supplements, yoga posture advice, and knee massage. Patients in the conventional group will receive self-care advice, pain medication, weight-loss advice (if overweight), and physiotherapy following current international guidelines. Both groups will receive 15 treatment sessions over 12 weeks. Outcomes will be evaluated after 6 and 12 weeks and 6 and 12 months. The primary endpoint is a change in the score on the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) after 12 weeks. Secondary outcome measurements will use WOMAC subscales, a pain disability index, a visual analog scale for pain and sleep quality, a pain experience scale, a quality-of-life index, a profile of mood states, and Likert scales for patient satisfaction, patient diaries, and safety. Using an adapted PRECIS scale, the trial was identified as lying mainly in the middle of the efficacy-effectiveness continuum. This trial is the first to compare the effectiveness of a complex Ayurvedic intervention with a complex conventional intervention in a Western medical setting in patients with knee osteoarthritis. During the trial design, aspects of efficacy and effectiveness were discussed. The resulting design is a compromise between rigor and pragmatism. NCT01225133.

A model for flexible tools used in minimally invasive medical virtual environments.

PubMed

Soler, Francisco; Luzon, M Victoria; Pop, Serban R; Hughes, Chris J; John, Nigel W; Torres, Juan Carlos

2011-01-01

Within the limits of current technology, many applications of a virtual environment will trade-off accuracy for speed. This is not an acceptable compromise in a medical training application where both are essential. Efficient algorithms must therefore be developed. The purpose of this project is the development and validation of a novel physics-based real time tool manipulation model, which is easy to integrate into any medical virtual environment that requires support for the insertion of long flexible tools into complex geometries. This encompasses medical specialities such as vascular interventional radiology, endoscopy, and laparoscopy, where training, prototyping of new instruments/tools and mission rehearsal can all be facilitated by using an immersive medical virtual environment. Our model recognises and uses accurately patient specific data and adapts to the geometrical complexity of the vessel in real time.

Neurohormones and heart failure.

PubMed

Mendzef, Scott D; Slovinski, Jennifer R

2004-12-01

The management of several neurohormonal pathways is crucial to treating the progression of HF, in addition to improving the quality of life for patients diagnosed with HF. Stimulation of the sympathetic and retin-angiogensin-aldosterone systems begins the initial and primary neurohormonal stimulation associated with the progression of this disease. However, it is becoming increasingly evident that other systems, including the cellular immune, endothelin-NO pathway, kallikrein-kinin system, the arachidonic acid cascade, and the natriuretic peptides need to be considered by clinicians when treating HF. Once treated solely with nitrates, diuretics, and morphine, the management of HF is becoming a more complex and intricate balancing act among several interdependent neurohormonal systems. Understanding the complex nature and proper management of these systems are crucial if patients with HF are to enjoy a better quality of life and experience an improvement in their symptoms. Current recommendations for the treatment and management of HF use several medications, which affect multiple neurohormonal pathways. The Heart Failure Society of America and the American Heart Association both recommend in their recent guidelines for management of HF the use of beta-adrenergic receptor blockers (beta-blockers), loop diuretics, digitalis glycosides(digoxin), ACE-I, aldactone antagonists (spironolactone), and in selected instances, ARBs and the combination of hydralazine and isosorbide dinitrate. No discussion of HF is complete without mention of the larger challenges associated with the management of HF. It is a complex syndrome that requires a multidisciplinary approach with expertise in nutrition, exercise, pharmacology, education, and the basic pathophysiology of complex neurohormonal systems. Patients with uncompensated HF are frightened, vulnerable, and require frequent medication adjustments as well as substantial time dedicated to counseling, physical assessment, and innovative educational programs for them and their families. In fact, a majority of hospital readmissions for HF occur because of patients' dietary indiscretions, medication noncompliance, or ignorance about when to call their health providers. The management of HF represents a careful balancing act between powerful neurohormonal pathways and medications but also between the basics of diet, exercise, educating both family and patient, and most importantly, caring.

Creating opportunities for interdisciplinary collaboration and patient-centred care: how nurses, doctors, pharmacists and patients use communication strategies when managing medications in an acute hospital setting.

PubMed

Liu, Wei; Gerdtz, Marie; Manias, Elizabeth

2016-10-01

This paper examines the communication strategies that nurses, doctors, pharmacists and patients use when managing medications. Patient-centred medication management is best accomplished through interdisciplinary practice. Effective communication about managing medications between clinicians and patients has a direct influence on patient outcomes. There is a lack of research that adopts a multidisciplinary approach and involves critical in-depth analysis of medication interactions among nurses, doctors, pharmacists and patients. A critical ethnographic approach with video reflexivity was adopted to capture communication strategies during medication activities in two general medical wards of an acute care hospital in Melbourne, Australia. A mixed ethnographic approach combining participant observations, field interviews, video recordings and video reflexive focus groups and interviews was employed. Seventy-six nurses, 31 doctors, 1 pharmacist and 27 patients gave written consent to participate in the study. Data analysis was informed by Fairclough's critical discourse analytic framework. Clinicians' use of communication strategies was demonstrated in their interpersonal, authoritative and instructive talk with patients. Doctors adopted the language discourse of normalisation to standardise patients' illness experiences. Nurses and pharmacists employed the language discourses of preparedness and scrutiny to ensure that patient safety was maintained. Patients took up the discourse of politeness to raise medication concerns and question treatment decisions made by doctors, in their attempts to challenge decision-making about their health care treatment. In addition, the video method revealed clinicians' extensive use of body language in communication processes for medication management. The use of communication strategies by nurses, doctors, pharmacists and patients created opportunities for improved interdisciplinary collaboration and patient-centred medication management in an acute hospital setting. Language discourses shaped and were shaped by complex power relations between patients and clinicians and among clinicians themselves. Clinicians need to be encouraged to have regular conversations to talk about and challenge each other's practices. More emphasis should be placed on ensuring that patients are given opportunities to voice their concerns about how their medications are managed. © 2016 John Wiley & Sons Ltd.

A two-step approach for mining patient treatment pathways in administrative healthcare databases.

PubMed

Najjar, Ahmed; Reinharz, Daniel; Girouard, Catherine; Gagné, Christian

2018-05-01

Clustering electronic medical records allows the discovery of information on healthcare practices. Entries in such medical records are usually composed of a succession of diagnostics or therapeutic steps. The corresponding processes are complex and heterogeneous since they depend on medical knowledge integrating clinical guidelines, the physician's individual experience, and patient data and conditions. To analyze such data, we are first proposing to cluster medical visits, consultations, and hospital stays into homogeneous groups, and then to construct higher-level patient treatment pathways over these different groups. These pathways are then also clustered to distill typical pathways, enabling interpretation of clusters by experts. This approach is evaluated on a real-world administrative database of elderly people in Québec suffering from heart failures. Copyright © 2018 Elsevier B.V. All rights reserved.

Patient, physician and presentational influences on clinical decision making for breast cancer: results from a factorial experiment.

PubMed

McKinlay, J B; Burns, R B; Durante, R; Feldman, H A; Freund, K M; Harrow, B S; Irish, J T; Kasten, L E; Moskowitz, M A

1997-02-01

This study examines the influence of six patient characteristics (age, race, socioeconomic status, comorbidities, mobility and presentational style) and two physician characteristics (medical specialty and years of clinical experience) on physicians' clinical decision making behaviour in the evaluation treatment of an unknown and known breast cancer. Physicians' variability and certainty associated with diagnostic and treatment behaviour were also examined. Separate analyses explored the influence of these non-medical factors on physicians' cognitive processes. Using a fractional factorial design, 128 practising physicians were shown two videotaped scenarios and asked about possible diagnoses and medical recommendations. Results showed that physicians displayed considerable variability in response to several patient-based factors. Physician characteristics also emerged as important predictors of clinical behaviour, thus confirming the complexity of the medical decision-making process.

Medication adherence perspectives in haemodialysis patients: a qualitative study.

PubMed

Ghimire, Saurav; Castelino, Ronald L; Jose, Matthew D; Zaidi, Syed Tabish R

2017-05-22

End-stage kidney disease patients undergoing haemodialysis are prescribed with multiple complex regimens and are predisposed to high risk of medication nonadherence. The aims of this study were to explore factors associated with medication adherence, and, to examine the differential perspectives on medication-taking behaviour shown by adherent and nonadherent haemodialysis patients. A qualitative exploratory design was used. One-on-one semi-structured interviews were conducted with 30 haemodialysis patients at the outpatient dialysis facility in Hobart, Australia. Patient self-reported adherence was measured using 4-item Morisky Green Levine scale. Interview transcripts were thematically analysed and mapped against the World Health Organization (WHO) determinants of medication adherence. Participants were 44-84 years old, and were prescribed with 4-19 medications daily. More than half of the participants were nonadherent to their medications based on self-reported measure (56.7%, n = 17). Themes mapped against WHO adherence model comprised of patient-related (knowledge, awareness, attitude, self-efficacy, action control, and facilitation); health system/ healthcare team related (quality of interaction, and mistrust and collateral arrangements); therapy-related (physical characteristics of medicines, packaging, and side effects); condition-related (symptom severity); and social/ economic factors (access to medicines, and relative affordability). Patients expressed a number of concerns that led to nonadherence behaviour. Many of the issues identified were patient-related and potentially modifiable by using psycho-educational or cognitive-behavioural interventions. Healthcare professionals should be more vigilant towards identifying these concerns to address adherence issues. Future research should be aimed at understanding healthcare professionals' perceptions and practices of assessing medication adherence in dialysis patients that may guide intervention to resolve this significant issue of medication nonadherence.

[Medical doctors driving technological innovation: questions about and innovation management approaches to incentive structures for lead users].

PubMed

Bohnet-Joschko, Sabine; Kientzler, Fionn

2010-01-01

Management science defines user-generated innovations as open innovation and lead user innovation. The medical technology industry finds user-generated innovations profitable and even indispensable. Innovative medical doctors as lead users need medical technology innovations in order to improve patient care. Their motivation to innovate is mostly intrinsic. But innovations may also involve extrinsic motivators such as gain in reputation or monetary incentives. Medical doctors' innovative activities often take place in hospitals and are thus embedded into the hospital's organisational setting. Hospitals find it difficult to gain short-term profits from in-house generated innovations and sometimes hesitate to support them. Strategic investment in medical doctors' innovative activities may be profitable for hospitals in the long run if innovations provide first-mover competitive advantages. Industry co-operations with innovative medical doctors offer chances but also bear potential risks. Innovative ideas generated by expert users may result in even higher complexity of medical devices; this could cause mistakes when applied by less specialised users and thus affect patient safety. Innovations that yield benefits for patients, medical doctors, hospitals and the medical technology industry can be advanced by offering adequate support for knowledge transfer and co-operation models.

A systematic review of patient medication error on self-administering medication at home.

PubMed

Mira, José Joaquín; Lorenzo, Susana; Guilabert, Mercedes; Navarro, Isabel; Pérez-Jover, Virtudes

2015-06-01

Medication errors have been analyzed as a health professionals' responsibility (due to mistakes in prescription, preparation or dispensing). However, sometimes, patients themselves (or their caregivers) make mistakes in the administration of the medication. The epidemiology of patient medication errors (PEs) has been scarcely reviewed in spite of its impact on people, on therapeutic effectiveness and on incremental cost for the health systems. This study reviews and describes the methodological approaches and results of published studies on the frequency, causes and consequences of medication errors committed by patients at home. A review of research articles published between 1990 and 2014 was carried out using MEDLINE, Web-of-Knowledge, Scopus, Tripdatabase and Index Medicus. The frequency of PE was situated between 19 and 59%. The elderly and the preschooler population constituted a higher number of mistakes than others. The most common were: incorrect dosage, forgetting, mixing up medications, failing to recall indications and taking out-of-date or inappropriately stored drugs. The majority of these mistakes have no negative consequences. Health literacy, information and communication and complexity of use of dispensing devices were identified as causes of PEs. Apps and other new technologies offer several opportunities for improving drug safety.

Learning to attain an advanced level of professional responsibility.

PubMed

Ter Maten-Speksnijder, Ada; Grypdonck, Mieke; Pool, Aart; Meurs, Pauline; Van Staa, AnneLoes

2015-08-01

After graduation, nurse practitioner students are expected to be capable of providing complex, evidence-based nursing care independently, combined with standardized medical care. The students who follow work-study programs have to develop their competencies in a healthcare environment dominated by efficiency policies. This study aims to explore nurse practitioner students' perceptions of their professional responsibility for patient care. This qualitative interpretative study entails a content analysis of 46 reflective case studies written by nurse practitioner students. The students felt responsible for the monitoring of patients' health status, attending to psychosocial problems, emphasizing compliance, and optimizing the family's role as informal caregivers. At the same time, students struggled to understand the complexities of their patients' needs, and they had difficulty applying their knowledge and skills to complex medical, psychological, and social problems. The students' perceptions of their new responsibility were characterized by a strong focus on curative care, while psychosocial components of health and illness concerns were often overlooked. The students experienced difficulties in meeting the criteria of advanced practice nursing described in the Dutch competency framework. Copyright © 2015 Elsevier Ltd. All rights reserved.

Sympathetic blocks for the treatment of complex regional pain syndrome: A case series.

PubMed

Gungor, Semih; Aiyer, Rohit; Baykoca, Buse

2018-05-01

To present the successful treatment of complex regional pain syndrome type -1 utilizing sympathetic blocks. Severe pain interfering with activities of daily living and temporary disability secondary to complex regional pain syndrome. Complex regional pain syndrome type-1 with involvement of lower extremity (2 patients), and upper extremity (1 patient). We report the management of 3 patients with diagnosis of complex regional pain syndrome type-1 by early institution of sympathetic blocks for diagnostic and therapeutic purposes. All 3 patients were able to tolerate physical therapy only after adequate pain relief had been achieved with institution of sympathetic blocks. All 3 patients responded very favorably to sympathetic blocks with dramatic reversal of pathology. All patients reported almost complete resolution of pain, symptoms, and signs within 6 months duration after diagnosis of complex regional pain syndrome. All 3 patients were able to wean their pain medications and achieve normal activities of daily living without any significant limitations. All patients were able to return to full-time employment. Treatment options are limited and there is lack of high quality research regarding the efficacy of sympathetic blocks in the treatment of complex regional pain syndrome. As presented in this case series, sympathetic blocks maybe very effective in the treatment of complex regional pain syndrome in a subset of patients. Thus, early institution of sympathetic blocks should be considered in complex regional pain syndrome prior to physical therapy and consideration of more invasive pain management interventions.

Towards non-reductionistic medical anthropology, medical education and practitioner-patient-interaction: the example of Anthroposophic Medicine.

PubMed

Heusser, Peter; Scheffer, Christian; Neumann, Melanie; Tauschel, Diethart; Edelhäuser, Friedrich

2012-12-01

To develop the hypothesis that reductionism in medical anthropology, professional education and health care influences empathy development, communication and patient satisfaction. We identified relevant literature and reviewed the material in a structured essay. We reflected our hypothesis by applying it to Anthroposophic Medicine (AM), an example of holistic theory and practice. Reductionism in medical anthropology such as in conventional medicine seems to lead to a less empathetic and less communicative health care culture than holism such as in CAM disciplines. However, reductionism can be transformed into a systemic, multi-perspective holistic view, when the emergent properties of the physical, living, psychic, spiritual and social levels of human existence and the causal relations between them are more carefully accounted for in epistemology, medical anthropology and professional education. This is shown by the example of AM and its possible benefits for communication with and satisfaction of patients. A non-reductionistic understanding of the human being may improve communication with patients and enhance patient benefit and satisfaction. Interdisciplinary qualitative and quantitative studies are warranted to test this hypothesis and to understand the complex relations between epistemology, medical anthropology, education, health care delivery and benefit for patients. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Effect of Work Complexity & Individual Differences on Nursing IT Utilization

ERIC Educational Resources Information Center

Tian, Renran

2013-01-01

Various healthcare IT systems have been developed to reduce medication errors. Although these systems can help to improve patient safety and reduce adverse medical events, new problems are also generated with their utilizations. One key problem during IT implementation is the change of working process. Although many of these changes are recorded…

Competencies for the new postdoctoral Oral Medicine graduate in the United States.

PubMed

Whitney, Eli M; Stoopler, Eric; Brennan, Michael T; DeRossi, Scott S; Treister, Nathaniel S

2015-09-01

Oral Medicine is primarily a nonsurgical dental discipline that includes management of (1) oral mucosal and salivary gland diseases; (2) temporomandibular disorders and orofacial pain; (3) oral complications of systemic disease; and (4) dental management of medically complex patients within its scope of practice. In the United States, the American Academy of Oral Medicine (AAOM) is the professional organization that primarily supports Oral Medicine education, research, and patient care. This document informs the knowledge, skills, and behaviors of beginning Oral Medicine graduates in the United States in three domains: Diagnosis and primarily nonsurgical management of oral mucosal and salivary gland disorders. Diagnosis and primarily nonsurgical management of temporomandibular, orofacial pain, and neurosensory disorders. Management of the medically complex patient. Each domain is subsequently expanded with major competencies and supporting competencies. Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.

Medical history and the onset of complex regional pain syndrome (CRPS).

PubMed

de Mos, M; Huygen, F J P M; Dieleman, J P; Koopman, J S H A; Stricker, B H Ch; Sturkenboom, M C J M

2008-10-15

Knowledge concerning the medical history prior to the onset of complex regional pain syndrome (CRPS) might provide insight into its risk factors and potential underlying disease mechanisms. To evaluate prior to CRPS medical conditions, a case-control study was conducted in the Integrated Primary Care Information (IPCI) project, a general practice (GP) database in the Netherlands. CRPS patients were identified from the records and validated through examination by the investigator (IASP criteria) or through specialist confirmation. Cases were matched to controls on age, gender and injury type. All diagnoses prior to the index date were assessed by manual review of the medical records. Some pre-specified medical conditions were studied for their association with CRPS, whereas all other diagnoses, grouped by pathogenesis, were tested in a hypothesis-generating approach. Of the identified 259 CRPS patients, 186 cases (697 controls) were included, based on validation by the investigator during a visit (102 of 134 visited patients) or on specialist confirmation (84 of 125 unvisited patients). A medical history of migraine (OR: 2.43, 95% CI: 1.18-5.02) and osteoporosis (OR: 2.44, 95% CI: 1.17-5.14) was associated with CRPS. In a recent history (1-year before CRPS), cases had more menstrual cycle-related problems (OR: 2.60, 95% CI: 1.16-5.83) and neuropathies (OR: 5.7; 95% CI: 1.8-18.7). In a sensitivity analysis, including only visited cases, asthma (OR: 3.0; 95% CI: 1.3-6.9) and CRPS were related. Psychological factors were not associated with CRPS onset. Because of the hypothesis-generating character of this study, the findings should be confirmed by other studies.

Health-economic outcomes in hospital patients with medical-psychiatric comorbidity: A systematic review and meta-analysis

PubMed Central

van Schijndel, Maarten; van Waarde, Jeroen; van Busschbach, Jan

2018-01-01

Background Hospital inpatients often experience medical and psychiatric problems simultaneously. Although this implies a certain relationship between healthcare utilization and costs, this relationship has never been systematically reviewed. Objective The objective is to examine the extent to which medical-psychiatric comorbidities relate to health-economic outcomes in general and in different subgroups. If the relationship is significant, this would give additional reasons to facilitate the search for targeted and effective treatments for this complex population. Method A systematic review in Embase, Medline, Psycinfo, Cochrane, Web of Science and Google Scholar was performed up to August 2016 and included cross-references from included studies. Only peer-reviewed empirical studies examining the impact of inpatient medical-psychiatric comorbidities on three health-economic outcomes (length of stay (LOS), medical costs and rehospitalizations) were included. Study design was not an exclusion criterion, there were no restrictions on publication dates and patients included had to be over 18 years. The examined populations consisted of inpatients with medical-psychiatric comorbidities and controls. The controls were inpatients without a comorbid medical or psychiatric disorder. Non-English studies were excluded. Results From electronic literature databases, 3165 extracted articles were scrutinized on the basis of title and abstract. This resulted in a full-text review of 86 articles: 52 unique studies were included. The review showed that the presence of medical-psychiatric comorbidity was related to increased LOS, higher medical costs and more rehospitalizations. The meta-analysis revealed that patients with comorbid depression had an increased mean LOS of 4.38 days compared to patients without comorbidity (95% CI: 3.07 to 5.68, I2 = 31%). Conclusions Medical-psychiatric comorbidity is related to increased LOS, medical costs and rehospitalization; this is also shown for specific subgroups. This study had some limitations; namely, that the studies were very heterogenetic and, in some cases, of poor quality in terms of risk of bias. Nevertheless, the findings remain valid and justify the search for targeted and effective interventions for this complex population. PMID:29534097

Medical Decision-Making Among Adolescents with Neonatal Brachial Plexus Palsy and their Families: A Qualitative Study

PubMed Central

Squitieri, Lee; Larson, Bradley P.; Chang, Kate W-C; Yang, Lynda J-S.; Chung, Kevin C.

2016-01-01

Background Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with NBPP and their families faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process. Patients and Methods Eighteen adolescents with residual NBPP deficits between the ages of 10 to 17 years along with their parents were included in the present study. A qualitative research design was employed involving the use of separate one hour, in person, semi-structured interviews, which were audio recorded and transcribed. Grounded theory was applied by two independent members of the research team to identify recurrent themes and ultimately create a codebook that was then applied to the data. Results Medical decision-making among adolescents with NBPP and their families is multifaceted and individualized, comprised of both patient and system dependent factors. Four codes pertaining to the medical decision-making process were identified: 1) knowledge acquisition, 2) multidisciplinary care, 3) adolescent autonomy, and 4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system dependent factors, while adolescents largely based their medical decision-making on individual treatment desires to improve function and/or aesthetics. Conclusions There are many areas for improving the delivery of information and health care organization among adolescents with NBPP and their families. We recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. We believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing. PMID:23714810

Strategies to improve adherence to medications for cardiovascular diseases in socioeconomically disadvantaged populations: a systematic review.

PubMed

Laba, Tracey-Lea; Bleasel, Jonathan; Brien, Jo-Anne; Cass, Alan; Howard, Kirsten; Peiris, David; Redfern, Julie; Salam, Abdul; Usherwood, Tim; Jan, Stephen

2013-09-10

Medication non-adherence poses a major barrier to reducing cardiovascular disease (CVD) burden globally, and is increasingly recognised as a socioeconomically determined problem. Strategies promoting CVD medication adherence appear of moderate effectiveness and cost-effectiveness. Potentially, 'one-size-fits-all' measures are ill-equipped to address heterogeneous adherence behaviour between social groups. This review aims to determine the effects of strategies to improve adherence to CVD-related medications in socioeconomically disadvantaged groups. Randomised/quasi-randomised controlled trials (1996-June 2012, English), testing strategies to increase adherence to CVD-related medications prescribed to adult patients who may experience health inequity (place of residence, occupation, education, or socioeconomic position) were reviewed. 772 abstracts were screened, 111 full-text articles retrieved, and 16 full-text articles reporting on 14 studies, involving 7739 patients (age range 41-66 years), were included. Methodological and clinical heterogeneity precluded quantitative data synthesis. Studies were thematically grouped by targeted outcomes; underlying interventions and policies were classified using Michie et al.'s Behaviour Change Wheel. Contrasting with patient or physician/practice strategies, those simultaneously directed at patients and physicians/practices resulted in statistically significant improvements in relative adherence (16-169%). Comparative cost and cost-effectiveness analyses from three studies did not find cost-saving or cost-effective strategies. Unlike much current evidence in general populations, promising evidence exists about what strategies improve adherence in disadvantaged groups. These strategies were generally complex: simultaneously targeting patients and physicians; addressing social, financial, and treatment-related adherence barriers; and supported by broader guidelines, regulatory and communication-based policies. Given their complexity and potential resource implications, comprehensive process evaluations and cost and cost-effectiveness evidence are urgently needed. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Content and Usability Evaluation of Patient Oriented Drug-Drug Interaction Websites.

PubMed

Adam, Terrence J; Vang, Joseph

Drug-Drug Interactions (DDI) are an important source of preventable adverse drug events and a common reason for hospitalization among patients on multiple drug therapy regimens. DDI information systems are important patient safety tools with the capacity to identify and warn health professionals of clinically significant DDI risk. While substantial research has been completed on DDI information systems in professional settings such as community, hospital, and independent pharmacies; there has been limited research on DDI systems offered through online websites directly for use by ambulatory patients. The focus of this project is to test patient oriented website capacity to correctly identify drug interactions among well established and clinically significant medication combinations and convey clinical risk data to patients. The patient education capability was assessed by evaluating website Information Capacity, Patient Usability and Readability. The study results indicate that the majority of websites identified which met the inclusion and exclusion criteria operated similarly, but vary in risk severity assessment and are not optimally patient oriented to effectively deliver risk information. The limited quality of information and complex medical term content complicate DDI risk data conveyance and the sites may not provide optimal information delivery to allow medication consumers to understand and manage their medication regimens.

Interactions between patients and dental care providers: does gender matter?

PubMed

Inglehart, Marita R

2013-04-01

Research findings concerning the role of gender in patient-physician interactions can inform considerations about the role of gender in patient-dental care provider interactions. Medical research showed that gender differences in verbal and nonverbal communication in medical settings exist and that they affect the outcomes of these interactions. The process of communication is shaped by gender identities, gender stereotypes, and attitudes. Future research needs to consider the cultural complexity and diversity in which gender issues are embedded and the degree to which ongoing value change will shape gender roles and in turn interactions between dental patients and their providers. Copyright © 2013 Elsevier Inc. All rights reserved.

Surgical Management of Neurogenic Lower Urinary Tract Dysfunction.

PubMed

Gor, Ronak A; Elliott, Sean P

2017-08-01

Surgery for patients with neurogenic urinary tract dysfunction (nLUTD) is indicated when medical therapy fails, to correct conditions affecting patient safety, or when surgery can enhance the quality of life better than nonoperative management. Examples include failure of maximal medical therapy, inability to perform or aversion to clean intermittent catheterization, refractory incontinence, and complications from chronic, indwelling catheters. Adults with nLUTD have competing risk factors, including previous operations, obesity, poor nutritional status, complex living arrangements, impaired dexterity/paralysis, and impaired executive and cognitive function. Complications are common in this subgroup of patients requiring enduring commitments from surgeons, patients, and their caretakers. Copyright © 2017 Elsevier Inc. All rights reserved.

[Air rescue: current significance and practical issues].

PubMed

Schellhaaß, A; Popp, E

2014-12-01

Germany has a nationwide and powerful helicopter emergency medical services system (HEMS), which executes primary rescue missions and interhospital transfer of intensive care patients. In recent years the range of HEMS missions has become modified due to demographic changes and structural changes in the healthcare system. Furthermore, the number of HEMS missions is steadily increasing. If reasonably used air rescue contributes to desired reductions in overall preclinical time. Moreover, it facilitates prompt transport of patients to a hospital suitable for definitive medical care and treatment can be initiated earlier which is a particular advantage for severely injured and critically ill patients. Because of complex challenges during air rescue missions the qualifications of the HEMS personnel have to be considerably higher in comparison with ground based emergency medical services.

Calm to chaos: Engaging undergraduate nursing students with the complex nature of interruptions during medication administration.

PubMed

Hayes, Carolyn; Jackson, Debra; Davidson, Patricia M; Daly, John; Power, Tamara

2017-12-01

To describe undergraduate student nurse responses to a simulated role-play experience focussing on managing interruptions during medication administration. Improving patient safety requires that we find creative and innovative methods of teaching medication administration to undergraduate nurses in real-world conditions. Nurses are responsible for the majority of medication administrations in health care. Incidents and errors associated with medications are a significant patient safety issue and often occur as a result of interruptions. Undergraduate nursing students are generally taught medication administration skills in a calm and uninterrupted simulated environment. However, in the clinical environment medication administration is challenged by multiple interruptions. A qualitative study using convenience sampling was used to examine student perceptions of a simulated role-play experience. Data were collected from 451 of a possible 528 student written reflective responses and subject to thematic analysis. Students reported an increased understanding of the impacts of interruptions while administering medications and an improved awareness of how to manage disruptions. This study reports on one of three emergent themes: "Calm to chaos: engaging with the complex nature of clinical practice." Interrupting medication administration in realistic and safe settings facilitates awareness, allows for students to begin to develop management strategies in relation to interruption and increases their confidence. Students were given the opportunity to consolidate and integrate prior and new knowledge and skills through this role-play simulation. © 2017 John Wiley & Sons Ltd.

Reinforcing the Military in Military Medicine: Driving a Cultural Change in Investigating, Tracking and Training to Prevent Patient Safety Events in Military Facilities

DTIC Science & Technology

2011-04-01

habits, and the complex nature of health care operations resulting from team efforts. Concerns about medical liability from medical malpractice ...investigations as blame is easier to assign to one individual than to evaluate the layers of an organization for failures. Medical malpractice fears...Risk Manager will brief the MTF/CC and Executive Staff on MTF medical malpractice claims semi-annually as well as discuss lessons learned, systemic

Pediatric office emergencies.

PubMed

Fuchs, Susan

2013-10-01

Pediatricians regularly see emergencies in the office, or children that require transfer to an emergency department, or hospitalization. An office self-assessment is the first step in determining how to prepare for an emergency. The use of mock codes and skill drills make office personnel feel less anxious about medical emergencies. Emergency information forms provide valuable, quick information about complex patients for emergency medical services and other physicians caring for patients. Furthermore, disaster planning should be part of an office preparedness plan. Copyright © 2013 Elsevier Inc. All rights reserved.

Overview of medical errors and adverse events

PubMed Central

2012-01-01

Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures. PMID:22339769

A Standard Mutual Authentication Protocol for Cloud Computing Based Health Care System.

PubMed

Mohit, Prerna; Amin, Ruhul; Karati, Arijit; Biswas, G P; Khan, Muhammad Khurram

2017-04-01

Telecare Medical Information System (TMIS) supports a standard platform to the patient for getting necessary medical treatment from the doctor(s) via Internet communication. Security protection is important for medical records (data) of the patients because of very sensitive information. Besides, patient anonymity is another most important property, which must be protected. Most recently, Chiou et al. suggested an authentication protocol for TMIS by utilizing the concept of cloud environment. They claimed that their protocol is patient anonymous and well security protected. We reviewed their protocol and found that it is completely insecure against patient anonymity. Further, the same protocol is not protected against mobile device stolen attack. In order to improve security level and complexity, we design a light weight authentication protocol for the same environment. Our security analysis ensures resilience of all possible security attacks. The performance of our protocol is relatively standard in comparison with the related previous research.

Multimedia educational aids for improving consumer knowledge about illness management and treatment decisions: a review of randomized controlled trials.

PubMed

Jeste, Dilip V; Dunn, Laura B; Folsom, David P; Zisook, Dan

2008-01-01

Psychiatric practice is becoming increasingly more complex in terms of the available treatment options, use of new technologies for assessments, and a need for psychiatric patients and their caregivers to be familiar with general medical procedures. This trend will only intensify in the years to come. Routine methods of providing information relevant to clinical decision making about healthcare evaluations or management are often suboptimal. Relatively little research has been done on enhancing the capacity of psychiatric patients and the caregivers to make truly informed decisions about management. In this paper, we review studies that compared the effects of multimedia (video- or computer-based) educational aids with those of routine procedures to inform healthcare consumers about medical evaluations or management. Although most of these investigations were conducted in non-psychiatric patients, the results should be relevant for psychiatric practice of tomorrow. We searched MEDLINE, PsycINFO, and CINAHL bibliographic databases. Randomized controlled trials that used objective measures of knowledge or understanding of the information provided were selected. Studies were rated as positive if the multimedia educational aid resulted in a greater improvement in knowledge or understanding than the control condition. The quality of each study was also rated using a newly developed Scale for Assessing Scientific Quality of Investigations (SASQI). A total of 37 randomized controlled trials were identified. Nearly two-thirds of the studies (23/37) in diverse patient populations and for varied medical assessments and treatments reported that multimedia educational aids produced better understanding of information compared to routine methods. SASQI scores for the positive and negative studies were comparable, suggesting that lower quality was not related to positive findings. In conclusion, multimedia educational aids hold promise for improving the provision of complex medical information to patients and caregivers. It is likely that as psychiatric patients and their treating clinicians face increasingly complex choices regarding mental health treatment, multimedia decisional aids could become an effective supplement to the clinician patient interaction in near future.

Design for Additive Bio-Manufacturing: From Patient-Specific Medical Devices to Rationally Designed Meta-Biomaterials.

PubMed

Zadpoor, Amir A

2017-07-25

Recent advances in additive manufacturing (AM) techniques in terms of accuracy, reliability, the range of processable materials, and commercial availability have made them promising candidates for production of functional parts including those used in the biomedical industry. The complexity-for-free feature offered by AM means that very complex designs become feasible to manufacture, while batch-size-indifference enables fabrication of fully patient-specific medical devices. Design for AM (DfAM) approaches aim to fully utilize those features for development of medical devices with substantially enhanced performance and biomaterials with unprecedented combinations of favorable properties that originate from complex geometrical designs at the micro-scale. This paper reviews the most important approaches in DfAM particularly those applicable to additive bio-manufacturing including image-based design pipelines, parametric and non-parametric designs, metamaterials, rational and computationally enabled design, topology optimization, and bio-inspired design. Areas with limited research have been identified and suggestions have been made for future research. The paper concludes with a brief discussion on the practical aspects of DfAM and the potential of combining AM with subtractive and formative manufacturing processes in so-called hybrid manufacturing processes.

Design for Additive Bio-Manufacturing: From Patient-Specific Medical Devices to Rationally Designed Meta-Biomaterials

PubMed Central

Zadpoor, Amir A.

2017-01-01

Recent advances in additive manufacturing (AM) techniques in terms of accuracy, reliability, the range of processable materials, and commercial availability have made them promising candidates for production of functional parts including those used in the biomedical industry. The complexity-for-free feature offered by AM means that very complex designs become feasible to manufacture, while batch-size-indifference enables fabrication of fully patient-specific medical devices. Design for AM (DfAM) approaches aim to fully utilize those features for development of medical devices with substantially enhanced performance and biomaterials with unprecedented combinations of favorable properties that originate from complex geometrical designs at the micro-scale. This paper reviews the most important approaches in DfAM particularly those applicable to additive bio-manufacturing including image-based design pipelines, parametric and non-parametric designs, metamaterials, rational and computationally enabled design, topology optimization, and bio-inspired design. Areas with limited research have been identified and suggestions have been made for future research. The paper concludes with a brief discussion on the practical aspects of DfAM and the potential of combining AM with subtractive and formative manufacturing processes in so-called hybrid manufacturing processes. PMID:28757572

Dutch Dataset Pain Rehabilitation in daily practice: Content, patient characteristics and reference data.

PubMed

Köke, A J A; Smeets, R J E M; Schreurs, K M; van Baalen, B; de Haan, P; Remerie, S C; Schiphorst Preuper, H R; Reneman, M F

2017-03-01

No core set of measurement tools exists to collect data within clinical practice. Such data could be useful as reference data to guide treatment decisions and to compare patient characteristics or treatment results within specific treatment settings. The Dutch Dataset Pain Rehabilitation was developed which included the six domains of the IMMPACT core set and three new domains relevant in the field of rehabilitation (medical consumption, patient-specific goals and activities/participation). Between 2010 and 2013 the core set was implemented in 32 rehabilitation facilities throughout the Netherlands. A total of 8200 adult patients with chronic pain completed the core set at first consultation with the rehabilitation physician. Adult patients (18-90 years) suffering from a long history of pain (38% >5 years) were referred. Patients had high medical consumption and less than half were working. Although patients were referred with diagnosis of low back pain or neck or shoulder pain, a large group (85%) had multisite pain (39% 2-5 painful body regions; 46% >5 painful body regions). Scores on psychosocial questionnaires were high, indicating high case complexity of referred patients. Reference data for subgroups based on gender, pain severity, pain locations and on pain duration are presented. The data from this clinical core set can be used to compare patient characteristics of patients of other treatment setting and/or scientific publications. As treatment success might depend on case complexity, which is high in the referred patients, the advantages of earlier referral to comprehensive multidisciplinary treatment were discussed. A detailed description of case complexity of patients with chronic pain referred for pain rehabilitation. Insight in case complexity of patients within subgroups on the basis of gender, pain duration, pain severity and pain location. These descriptions can be used as reference data for daily practice in the field of pain rehabilitation and can be used to evaluate, monitor and improve rehabilitation care in care settings nationwide as well as internationally. © 2016 European Pain Federation - EFIC®.

[Prospective assessment of medication errors in critically ill patients in a university hospital].

PubMed

Salazar L, Nicole; Jirón A, Marcela; Escobar O, Leslie; Tobar, Eduardo; Romero, Carlos

2011-11-01

Critically ill patients are especially vulnerable to medication errors (ME) due to their severe clinical situation and the complexities of their management. To determine the frequency and characteristics of ME and identify shortcomings in the processes of medication management in an Intensive Care Unit. During a 3 months period, an observational prospective and randomized study was carried out in the ICU of a university hospital. Every step of patient's medication management (prescription, transcription, dispensation, preparation and administration) was evaluated by an external trained professional. Steps with higher frequency of ME and their therapeutic groups involved were identified. Medications errors were classified according to the National Coordinating Council for Medication Error Reporting and Prevention. In 52 of 124 patients evaluated, 66 ME were found in 194 drugs prescribed. In 34% of prescribed drugs, there was at least 1 ME during its use. Half of ME occurred during medication administration, mainly due to problems in infusion rates and schedule times. Antibacterial drugs had the highest rate of ME. We found a 34% rate of ME per drug prescribed, which is in concordance with international reports. The identification of those steps more prone to ME in the ICU, will allow the implementation of an intervention program to improve the quality and security of medication management.

Challenges faced by primary care physicians when prescribing for patients with chronic diseases in a teaching hospital in Malaysia: a qualitative study.

PubMed

Sellappans, Renukha; Lai, Pauline Siew Mei; Ng, Chirk Jenn

2015-08-27

The aim of this study was to identify the challenges faced by primary care physicians (PCPs) when prescribing medications for patients with chronic diseases in a teaching hospital in Malaysia. 3 focus group discussions were conducted between July and August 2012 in a teaching primary care clinic in Malaysia. A topic guide was used to facilitate the discussions which were audio-recorded, transcribed verbatim and analysed using a thematic approach. PCPs affiliated to the primary care clinic were purposively sampled to include a range of clinical experience. Sample size was determined by thematic saturation of the data. 14 family medicine trainees and 5 service medical officers participated in this study. PCPs faced difficulties in prescribing for patients with chronic diseases due to a lack of communication among different healthcare providers. Medication changes made by hospital specialists, for example, were often not communicated to the PCPs leading to drug duplications and interactions. The use of paper-based medical records and electronic prescribing created a dual record system for patients' medications and became a problem when the 2 records did not tally. Patients sometimes visited different doctors and pharmacies for their medications and this resulted in the lack of continuity of care. PCPs also faced difficulties in addressing patients' concerns, and dealing with patients' medication requests and adherence issues. Some PCPs lacked time and knowledge to advise patients about their medications and faced difficulties in managing side effects caused by the patients' complex medication regimen. PCPs faced prescribing challenges related to patients, their own practice and the local health system when prescribing for patients with chronic diseases. These challenges must be addressed in order to improve chronic disease management in primary care and, more importantly, patient safety. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Effectiveness of a transitional home care program in reducing acute hospital utilization: a quasi-experimental study.

PubMed

Low, Lian Leng; Vasanwala, Farhad Fakhrudin; Ng, Lee Beng; Chen, Cynthia; Lee, Kheng Hock; Tan, Shu Yun

2015-03-14

Improving healthcare utilization is essential as health systems around the world grapple with the escalating demands for acute hospital resources. Evidence suggests that transitional care programs are effective to improve utilization of healthcare. However, the evidence for transitional care programs that enhance the home medical care model and provide multi-disciplinary patient-centered care is not well established. We evaluated if a transitional home care program operated by the Singapore General Hospital was effective in reducing acute hospital utilization. We performed a quasi-experimental study using a pre-post design to evaluate the effectiveness of a transitional home care program in reducing hospital admissions and emergency department attendances of medically complex patients enrolled into the program in a tertiary hospital in Singapore. Patients received a comprehensive needs assessment performed by the physician and a nurse case manager in the home setting, followed by an individualized care plan that included medical and nursing care, patient education and coordination of care with hospital specialists and community services. Primary study outcomes were emergency department attendances and hospital admissions to all hospitals. These were extracted from hospital administrative data and national health records. Wilcoxon Signed Ranks Test was used for assess differences in pre and post continuous data. Overall, 262 patients were enrolled into the program and 259 were analyzed. Patients had a 51.6% and 52.8% reduction in hospital admissions in the three-month and six-month post enrollment, respectively. Similarly, a 47.1% and 48.2% reduction was observed for emergency department attendances in the three and six months post enrollment, respectively. The average difference in per patient hospital bed days in the pre- and post-enrollment periods were 12.05 days and 20.03 days at the 3-month and 6-month periods, respectively. Patients enrolled in the transitional home care program had significantly lower acute hospital utilization through the reduction of emergency department attendances and hospital admissions. A comprehensive assessment of patients' medical and social needs in the home setting and formulation of an individualized care plan optimized post-discharge care for medically complex patients.

[Sexually transmitted diseases: the impact of stigma and taboo on current medical care].

PubMed

Badura-Lotter, G

2014-04-01

Sexually transmitted diseases (STD) are probably the most tabooed diseases we know. The many taboos and the related stigmata shape patients' lives and significantly influence health care policies, medical research, and current problems in medical ethics. To better understand these complex influences, the still powerful taboos and related metaphors associated with illness and disease are analyzed within their cultural and historical background and concerning the actual impact on patient care and research. It becomes obvious that research and health care policies cannot be satisfyingly successful in helping people affected by STDs as long as these "nonscientific" factors are not taken into account.

Touch massage: a pilot study of a complex intervention.

PubMed

Lindgren, Lenita; Lehtipalo, Stefan; Winsö, Ola; Karlsson, Marcus; Wiklund, Urban; Brulin, Christine

2013-11-01

To report and evaluate a complex touch massage intervention according to the British Medical Research Council framework. This study aimed to evaluate the effects of touch massage on levels of anxiety and physiological stress in patients scheduled for elective aortic surgery. The use of touch massage has increased during the past decade but no systematic studies have been implemented to investigate the effectiveness of such treatment. It is important to conduct multidisciplinary investigations into the effects of complex interventions such as touch massage. For this, the British Medical Research Council has provided a useful framework to guide the development, piloting, evaluation and reporting of complex intervention studies. A pilot study with a randomized controlled design including 20 patients (10 + 10) scheduled for elective aortic surgery. Selected outcome parameters included; self-reported anxiety, measured by the State-Trait Anxiety Inventory Form Y instrument, and physiological stress, measured by heart rate variability, blood pressure, respiratory frequency, oxygen saturation and concentrations of cortisol, insulin and glucose in serum. There were significant differences in self-reported anxiety levels before and after touch massage (p = 0.007), this was not observed in the control group (p = 0.833). There was a significant difference in self-reported anxiety levels between the touch massage group and the control group after touch massage and rest (p = 0.001). There were no significant differences in physiological stress-related outcome parameters between patients who received touch massage and controls. In our study, touch massage decreased anxiety levels in patients scheduled for elective aortic surgery, and the British Medical Research Council framework was a useful guideline for the development, evaluation and reporting of a touch massage intervention. Touch massage can reduce patients' anxiety levels and is thus an important nursing intervention in intensive and post-operative care. © 2013 The Authors. Nursing in Critical Care © 2013 British Association of Critical Care Nurses.

From problem solving to problem definition: scrutinizing the complex nature of clinical practice.

PubMed

Cristancho, Sayra; Lingard, Lorelei; Regehr, Glenn

2017-02-01

In medical education, we have tended to present problems as being singular, stable, and solvable. Problem solving has, therefore, drawn much of medical education researchers' attention. This focus has been important but it is limited in terms of preparing clinicians to deal with the complexity of the 21st century healthcare system in which they will provide team-based care for patients with complex medical illness. In this paper, we use the Soft Systems Engineering principles to introduce the idea that in complex, team-based situations, problems usually involve divergent views and evolve with multiple solution iterations. As such we need to shift the conversation from (1) problem solving to problem definition, and (2) from a problem definition derived exclusively at the level of the individual to a definition derived at the level of the situation in which the problem is manifested. Embracing such a focus on problem definition will enable us to advocate for novel educational practices that will equip trainees to effectively manage the problems they will encounter in complex, team-based healthcare.

A national house-staff audit of medical prophylaxis in medical patients for the PREVENTion of Venous ThromboEmbolism (PREVENT-VTE).

PubMed

Adamali, H; Suliman, A M; Zaid, H; O'Donoghue, E; Burke, A; Suliman, A W; Salem, M; O'Toole, A; Yearoo, A Ibrahim; Javid, S; Ullah, I; Bolger, K; Dunican, E; McCullagh, B; Curtin, D; Lonergan, M T; Dillon, L; Murphy, A W; Gaine, S

2013-01-01

We established a national audit to assess the thromboprophylaxis rate for venous thromoembolism (VTE) in at risk medical patients in acute hospitals in the Republic of Ireland and to determine whether the use of stickers to alert physicians regarding thromboprophylaxis would double the rate prophylaxis in a follow-up audit. 651 acute medical admission patients in the first audit and 524 in the second re-audit were recruited. The mean age was 66.5 yrs with similar numbers of male and female patients and 265 (22.6%) patients were active smokers. The first and second audits identified 549 (84%) and 487 (93%) of patients at-risk for VTE respectively. Of the at-risk patients, 163 (29.7%) and 132 (27.1%) received LMWH in the first and second audit respectively. Mechanical thromboprophylaxis was instigated in 75 (13.6%) patients in the first and 86 (17.7%) patients in the second audit. The placement of stickers in patient charts didn't produce a significant increase in the number of at risk patients treated in the second audit. There is unacceptably low adherence to the ACCP guidelines in Ireland and more complex intervention than chart reminders are required to improve compliance.

A needs assessment to determine the need for respiratory therapy in complex continuing care: A methods paper.

PubMed

Nickerson, Jason W

2015-01-01

There is an emerging demand for complex continuing care for patients who are too ill to safely return home, but for whom hospitalization in an acute care environment is unnecessary or inappropriate. Despite the need and medical complexity of these patients, few respiratory therapists are practising in this environment, and little evidence exists to guide the implementation of respiratory therapy services in this setting. In response to a perceived need for greater respiratory services at Saint Vincent Hospital (Ottawa, Ontario), a needs assessment was undertaken to assess the prevalence of respiratory diseases and for increased respiratory therapist coverage at this complex continuing care hospital. An initial literature review was conducted to guide the assessment, and identified only one tool of relevance, which was obtained and formed the basis of the further development of tools for collecting data at the hospital level and on patient care units at the facility. This needs assessment tool was expanded to include priority areas of relevance that fall within the scope of practice of respiratory therapists, and was supplemented by the analysis of administrative databases and qualitative data gathered through unit walkthroughs and unstructured key informant interviews. A health systems framework was used to structure recommendations for the development of interventions and programs for this patient population. The burden of respiratory disease was significant, and included a high prevalence of inhaled medication and oxygen use, and a significant workload that could be attributed to addressing the respiratory needs of patients. A range of tools and methods are needed to conduct needs assessments for respiratory therapy in complex continuing care. Using multiple data sources, a significant burden of respiratory diseases was present at the Saint Vincent Hospital; further studies in other complex continuing care hospitals are needed to understand the significance of these findings among this patient population more generally.

Performance of a radio link between a base station and a medical implant utilising the MICS standard.

PubMed

Johansson, Anders J

2004-01-01

Modern medical implants are of increasing complexity and with that, the need for fast and flexible communication with them grows. A wireless system is preferable and an inductive link is the most commonly used. But it has the drawback of a very short range, essentially limited to having the external transceiver touching the patient. The Medical Implant Communication System, MICS, is a standard aimed at improving the communication distance. It operates at a higher frequency band between 402 MHz and 405 MHz. We have by simulations and measurements investigated the channel properties of this band and calculated the link performance for a typical implant application. The result is a link speed between a base station and a bedridden patient of 600 kbit bits per second with a bit error rate of 2% in the downlink to the implant and 1 % in the uplink to the base station. Conclusions on the necessary complexity of the base station are also given.

Retrieval and management of medical information from heterogeneous sources, for its integration in a medical record visualisation tool.

PubMed

Cabarcos, Alba; Sanchez, Tamara; Seoane, Jose A; Aguiar-Pulido, Vanessa; Freire, Ana; Dorado, Julian; Pazos, Alejandro

2010-01-01

Nowadays, medical practice needs, at the patient Point-of-Care (POC), personalised knowledge adjustable in each moment to the clinical needs of each patient, in order to provide support to decision-making processes, taking into account personalised information. To achieve this, adapting the hospital information systems is necessary. Thus, there is a need of computational developments capable of retrieving and integrating the large amount of biomedical information available today, managing the complexity and diversity of these systems. Hence, this paper describes a prototype which retrieves biomedical information from different sources, manages it to improve the results obtained and to reduce response time and, finally, integrates it so that it is useful for the clinician, providing all the information available about the patient at the POC. Moreover, it also uses tools which allow medical staff to communicate and share knowledge.

Science in the Service of Patients: Lessons from the Past in the Moral Battle for the Future of Medical Education

PubMed Central

Weisberg, Daniel F.

2014-01-01

Medical schools instill a classic moral standoff in which the responsibility for the betterment of the patient stands at odds with the responsibility for the betterment of society. In critical ways, the latter, in the form of a robust research and technology-driven enterprise, has taken precedence over the former, resulting in harm to patients and individual dignity. This tradeoff can be traced to Abraham Flexner, the father of American medical education. In the wake of the Flexner report, American medicine set out on a course of exponential scientific advancement, but the mistreatment of research subjects and the erosion of the doctor-patient relationship in a health care system that is increasingly unaffordable, complex, and impersonal suggest that such progress has come at a price. Recent efforts by medical schools to emphasize humanism in their curricula and admissions processes have shown promise in orienting the values of academic medicine toward the individual patient’s well-being. PMID:24600339

Collaboration Between Surgeons and Medical Oncologists and Outcomes for Patients With Stage III Colon Cancer.

PubMed

Hussain, Tanvir; Chang, Hsien-Yen; Veenstra, Christine M; Pollack, Craig E

2015-05-01

Collaboration between specialists is essential for achieving high-value care in patients with complex cancer needs. We explore how collaboration between oncologists and surgeons affects mortality and cost for patients requiring multispecialty cancer care. This was a retrospective cohort study of patients with stage III colon cancer from SEER-Medicare diagnosed between 2000 and 2009. Patients were assigned to a primary treating surgeon and oncologist. Collaboration between surgeon and oncologist was measured as the number of patients shared between them; this has been shown to reflect advice seeking and referral relationships between physicians. Outcomes included hazards for all-cause mortality, subhazards for colon cancer-specific mortality, and cost of care at 12 months. A total of 9,329 patients received care from 3,623 different surgeons and 2,319 medical oncologists, representing 6,827 unique surgeon-medical oncologist pairs. As the number of patients shared between specialists increased from to one to five (25th to 75th percentile), patients experienced an approximately 20% improved survival benefit from all-cause and colon cancer-specific mortalities. Specifically, for each additional patient shared between oncologist and surgeon, all-cause mortality improved by 5% (hazard ratio, 0.95; 95%CI, 0.92 to 0.97), and colon cancer-specific mortality improved by 5% (subhazard ratio, 0.95; 95% CI, 0.91 to 0.97). There was no association with cost. Specialist collaboration is associated with lower mortality without increased cost among patients with stage III colon cancer. Facilitating formal and informal collaboration between specialists may be an important strategy for improving the care of patients with complex cancers. Copyright © 2015 by American Society of Clinical Oncology.

The effects of human interest framing in television news coverage of medical advances.

PubMed

Hong, Hyehyun

2013-01-01

The last few decades have witnessed the increasing dissemination of information on medical advances such as new medical treatments and prevention/diagnosis technologies through television news. To engage lay audiences with complex information, medical journalists often personalize news stories about medical advances by exemplifying individual patients and their personal experiences. This study investigates the effects of this journalistic technique, which is referred to as human interest framing, on audiences. The results of an experiment provide empirical evidence that the human interest framing of medical news stories can increase audiences' involvement in those stories and facilitate their positive perception of medical advances.

Can the Tools of Activity Theory Help Us in Advancing Understanding and Organisational Change in Undergraduate Medical Education?

ERIC Educational Resources Information Center

Reid, Anne-Marie; Ledger, Alison; Kilminster, Sue; Fuller, Richard

2015-01-01

Continued changes to healthcare delivery in the UK, and an increasing focus on patient safety and quality improvement, require a radical rethink on how we enable graduates to begin work in challenging, complex environments. Professional regulatory bodies now require undergraduate medical schools to implement an "assistantship" period in…

Emergency Medical Services Providers' Perspective of End-of-Life Decision Making for People with Intellectual Disabilities

ERIC Educational Resources Information Center

McGinley, Jacqueline; Waldrop, Deborah P.; Clemency, Brian

2017-01-01

Background: Emergency medical services (EMS) providers are often called to rapidly determine and act upon patients' wishes for end-of-life care. People with intellectual disabilities are living increasingly longer with complex conditions leading to international calls for person-centred advance care planning. Yet, best estimates suggest that very…

Treating a physician patient with psychosis.

PubMed

Freedman, Jacob L; Crow, Fredrick F; Gutheil, Thomas G; Sanchez, Luis T; Suzuki, Joji

2012-06-01

The authors present a case of a psychotic female patient who is a former graduate of a locally prestigious medical school and has subsequently been diagnosed with schizophrenia. The patient entered treatment in an outpatient clinic following discharge from her 11th hospitalization. This hospitalization was initiated after the patient's physician friend had called the police and notified them that the patient was significantly disorganized to warrant further evaluation. Treatment was characterized by significant transference and counter-transference reactions amongst her clinicians - both treatment-promoting and treatment-interfering - based on her status as a physician. The problem of insight was a significant hurdle in the treatment of the patient as her medical knowledge of mental illness was substantially greater than her insight into her own mental illness. Throughout treatment, a number of medical-legal and ethical issues arose. Initially, the question was raised as to the legality of the actions by the patient's friend-having made a clinical assessment without having a clinical role in the patient's care. As the patient's clinical status improved and she sought to re-enter the medical field as a resident, new medical legal issues surfaced. What were the roles of the patient's treaters in maintaining confidentiality and simultaneously ensuring the safety of patients that the psychotic physician might care for? This case highlights the universality of psychiatric vulnerability. Insight in psychosis as well as the transference and counter-transference issues involved in caring for a psychotic physician are discussed. Additionally, a thorough medical-legal discussion addresses the various complexities of caring for a psychotic physician. Copyright © 2012 Elsevier B.V. All rights reserved.

Using machine learning to examine medication adherence thresholds and risk of hospitalization.

PubMed

Lo-Ciganic, Wei-Hsuan; Donohue, Julie M; Thorpe, Joshua M; Perera, Subashan; Thorpe, Carolyn T; Marcum, Zachary A; Gellad, Walid F

2015-08-01

Quality improvement efforts are frequently tied to patients achieving ≥80% medication adherence. However, there is little empirical evidence that this threshold optimally predicts important health outcomes. To apply machine learning to examine how adherence to oral hypoglycemic medications is associated with avoidance of hospitalizations, and to identify adherence thresholds for optimal discrimination of hospitalization risk. A retrospective cohort study of 33,130 non-dual-eligible Medicaid enrollees with type 2 diabetes. We randomly selected 90% of the cohort (training sample) to develop the prediction algorithm and used the remaining (testing sample) for validation. We applied random survival forests to identify predictors for hospitalization and fit survival trees to empirically derive adherence thresholds that best discriminate hospitalization risk, using the proportion of days covered (PDC). Time to first all-cause and diabetes-related hospitalization. The training and testing samples had similar characteristics (mean age, 48 y; 67% female; mean PDC=0.65). We identified 8 important predictors of all-cause hospitalizations (rank in order): prior hospitalizations/emergency department visit, number of prescriptions, diabetes complications, insulin use, PDC, number of prescribers, Elixhauser index, and eligibility category. The adherence thresholds most discriminating for risk of all-cause hospitalization varied from 46% to 94% according to patient health and medication complexity. PDC was not predictive of hospitalizations in the healthiest or most complex patient subgroups. Adherence thresholds most discriminating of hospitalization risk were not uniformly 80%. Machine-learning approaches may be valuable to identify appropriate patient-specific adherence thresholds for measuring quality of care and targeting nonadherent patients for intervention.

EARLY OR DELAYED SURGICAL TREATMENT IN COMPOUND LIMB FRACTURES DUE TO HIGH VELOCITY MISSILE INJURIES: A 5-YEAR RETROSPECTIVE STUDY FROM MEDICAL CITY IN BAGHDAD

PubMed Central

Al-Hilli, Ali Bakir; Salih, Dheyaa Saeed

2010-01-01

Background Compound limb fractures due to high-velocity missiles are complex and usually associated with multiple other injuries. These can occur in both military and civilian settings. Highvelocity missiles are presently used by terrorists worldwide. Early surgical debridement and skeletal fixation are the gold standards in managing these injuries, but data supporting these recommendations are lacking. Aim of the study Our aim was to determine the relationship between time (the time of injury to the time of surgical treatment) and the rate of deep infection in patients treated in Medical City, Baghdad, Iraq due to terrorist activity from 2004-2008. Design This is a retrospective review of a series of open limb fractures. Patients and method A total of 102 civilian patients with 114 limb fractures due to high-velocity missile injuries were selected for this study from Medical City records. Patients were followed in the outpatient department in Medical City Teaching Complex both clinically and radiologically. Results Surgical treatment was accomplished in less than six hours from time of injury in group A (55 fractures, 48.4%) and more than six hours in group B (59 fractures, 51.7%). The infection rate for group A was 30.9% and group B was 23.7%. Conclusion A very high infection rate was noted for these injuries, and there was no increase in the rate of deep infection in patients treated more than six hours after the injury. PMID:21045979

Improvement of the complex medical treatment for the patients wіth chronic biliary pancreatitis.

PubMed

Babinets, L S; Kytsai, K Yu; Kotsaba, Yu Ya; Halabitska, I M; Melnyk, N A; Semenova, I V; Zemlyak, O S

The most common reason of chronic pancreatitis is liver and bile ducts disease: functional disorders, chronic cholecystitis, cholelithiasis and cholecystectomy in medical history. All these changes are associated with the colloidal structure of bile, increased lithogenicity, gallstones formation, Oddi's sphincter dysfunction, dysmotility and inflammation in the bile ducts. to study the effectiveness of using medicine Liveria IC (metadoxine) in standard therapy as well as effect on spectrum of blood serum lipids and structural condition of liver (stiffness) and pancreas in patients with chronic biliary pancreatitis combined with obesity. 115 patients suffering from chronic biliary pancreatitis and obesity were the subjects of the study. They were compared to etiological factor socioeconomic conditions and nutrition (regular food 5 times a day without aggressive food (fatty, spicy, sour, fried products)). Also the effect of the alcohol factor was excluded. The obtained decrease in stiffness of the liver and pancreas indicates an improvement of their structural state. Using medication LiveriaIC (metadoxine) as the part of the complex therapy for the patients who are suffering from CBP combined with obesity gives some improvement of the lipid profile indices and the structural condition of liver and pancreas (according to the data of SWE) (р<0.05).

The quinary pattern of blast injury.

PubMed

Kluger, Yoram; Nimrod, Adi; Biderman, Philippe; Mayo, Ami; Sorkin, Patric

2007-01-01

Bombing is the primary weapon of global terrorism, and it results in a complicated, multidimensional injury pattern. It induces bodily injuries through the well-documented primary, secondary, tertiary, and quaternary mechanisms of blast. Their effects dictate special medical concern and timely implementation of diagnostic and management strategies. Our objective is to report on clinical observations of patients admitted to the Tel Aviv Medical Center following a terrorist bombing. The explosion injured 27 patients, and three died. Four survivors who had been in close proximity to the explosion, as indicated by their eardrum perforation and additional blast injuries, were exposed to the blast wave. They exhibited a unique and immediate hyperinflammatory state, two upon admission to the intensive care unit and two during surgery. This hyperinflammatory state manifested as hyperpyrexia, sweating, low central venous pressure, and positive fluid balance. This state did not correlate with the complexity of injuries sustained by any of the 67 patients admitted to the intensive care unit after previous bombings. The patients' hyperinflammatory behavior, unrelated to their injury complexity and severity of trauma, indicates a new injury pattern in explosions, termed the "quinary blast injury pattern." Unconventional materials used in the manufacture of the explosive can partly explain the observed early hyperinflammatory state. Medical personnel caring for blast victims should be aware of this new type of bombing injury.

Automated medication reconciliation and complexity of care transitions.

PubMed

Silva, Pamela A Bozzo; Bernstam, Elmer V; Markowitz, Eliz; Johnson, Todd R; Zhang, Jiajie; Herskovic, Jorge R

2011-01-01

Medication reconciliation is a National Patient Safety Goal (NPSG) from The Joint Commission (TJC) that entails reviewing all medications a patient takes after a health care transition. Medication reconciliation is a resource-intensive, error-prone task, and the resources to accomplish it may not be routinely available. Computer-based methods have the potential to overcome these barriers. We designed and explored a rule-based medication reconciliation algorithm to accomplish this task across different healthcare transitions. We tested our algorithm on a random sample of 94 transitions from the Clinical Data Warehouse at the University of Texas Health Science Center at Houston. We found that the algorithm reconciled, on average, 23.4% of the potentially reconcilable medications. Our study did not have sufficient statistical power to establish whether the kind of transition affects reconcilability. We conclude that automated reconciliation is possible and will help accomplish the NPSG.

Lessons learned: mobile device encryption in the academic medical center.

PubMed

Kusche, Kristopher P

2009-01-01

The academic medical center is faced with the unique challenge of meeting the multi-faceted needs of both a modern healthcare organization and an academic institution, The need for security to protect patient information must be balanced by the academic freedoms expected in the college setting. The Albany Medical Center, consisting of the Albany Medical College and the Albany Medical Center Hospital, was challenged with implementing a solution that would preserve the availability, integrity and confidentiality of business, patient and research data stored on mobile devices. To solve this problem, Albany Medical Center implemented a mobile encryption suite across the enterprise. Such an implementation comes with complexities, from performance across multiple generations of computers and operating systems, to diversity of application use mode and end user adoption, all of which requires thoughtful policy and standards creation, understanding of regulations, and a willingness and ability to work through such diverse needs.

Medical homes: challenges in translating theory into practice.

PubMed

Carrier, Emily; Gourevitch, Marc N; Shah, Nirav R

2009-07-01

The concept of the medical home has existed since the 1960s, but has recently become a focus for discussion and innovation in the health care system. The most prominent definitions of the medical home are those presented by the Patient-Centered Primary Care Collaborative, the National Committee for Quality Assurance, and the Commonwealth Fund. These definitions share: adoption of health information technology and decision support systems, modification of clinical practice patterns, and ensuring continuity of care. Each of these components is a complex undertaking, and there is scant evidence to guide assessment of diverse strategies for achieving their integration into a medical home. Without a shared vocabulary and common definitions, policy-makers seeking to encourage the development of medical homes, providers seeking to improve patient care, and payers seeking to develop appropriate systems of reimbursement will face challenges in evaluating and disseminating the medical home model.

Why medical students do not choose a career in geriatrics: a systematic review.

PubMed

Meiboom, Ariadne A; de Vries, Henk; Hertogh, Cees M P M; Scheele, Fedde

2015-06-05

While the demand for doctors specialised in the medical care of elderly patients is increasing, the interest among medical students for a career in geriatrics is lagging behind. To get an overview of the different factors reported in the literature that affect the (low) interest among medical students for a career in geriatrics, a systematic literature search was conducted using PubMed, Embase, PsycINFO, and ERIC. Quality assessment criteria were applied. Twenty studies met the criteria and were included in the review. In relation to the nature of the work, the preference of medical students is young patients, and acute somatic diseases that can be cured. The complexity of the geriatric patient deters students from choosing this specialty. Exposure by means of pre-clinical and particularly clinical education increases interest. The lack of status and the financial aspects have a negative influence on interest. Exposure to geriatrics by means of education is necessary. The challenge in geriatric education is to show the rewarding aspects of the specialty.

[The cost of polypharmacy in patients with type 2 diabetes mellitus].

PubMed

García A, Luz María; Villarreal R, Enrique; Galicia R, Liliana; Martínez G, Lidia; Vargas D, Emma Rosa

2015-05-01

Polypharmacy or the concomitant use of three or more medications, may increase the complexity of health care and its costs. To determine the costs of polypharmacy in patients with Type 2 Diabetes Mellitus in a Mexican population sample. Analysis of health care costs in 257 patients with Type 2 Diabetes Mellitus from two family care facilities, who had at least five consultations during one year. The cost of professional care by family physicians, pharmacological care and medications were considered to calculate the total expenses. The price of medications and the number of units consumed in one year were used to determine pharmacological expenses. Medications were grouped to determine costs derived from complications and concomitant diseases. Costs were calculated in US dollars (USD). The mean cost derived from family physician fees was USD 82.32 and from pharmacy fees USD 29.37. The mean cost of medications for diabetes treatment was USD 33.31, for the management of complications USD 13.9 and for management of concomitant diseases USD 23.7, rendering a total cost of USD 70.92. Thus, the total annual care cost of a diabetic patient was USD 182.61. Medications represent less than 50% of total expenses of diabetic patients with polypharmacy.

Challenges and opportunities of undertaking a video ethnographic study to understand medication communication.

PubMed

Liu, Wei; Gerdtz, Marie; Manias, Elizabeth

2015-12-01

To examine the challenges and opportunities of undertaking a video ethnographic study on medication communication among nurses, doctors, pharmacists and patients. Video ethnography has proved to be a dynamic and useful method to explore clinical communication activities. This approach involves filming actual behaviours and activities of clinicians to develop new knowledge and to stimulate reflections of clinicians on their behaviours and activities. However, there is limited information about the complex negotiations required to use video ethnography in actual clinical practice. Discursive paper. A video ethnographic approach was used to gain better understanding of medication communication processes in two general medical wards of a metropolitan hospital in Melbourne, Australia. This paper presents the arduous and delicate process of gaining access into hospital wards to video-record actual clinical practice and the methodological and ethical issues associated with video-recording. Obtaining access to clinical settings and clinician consent are the first hurdles of conducting a video ethnographic study. Clinicians may still feel intimidated or self-conscious in being video recorded about their medication communication practices, which they could perceive as judgements being passed about their clinical competence. By thoughtful and strategic planning, video ethnography can provide in-depth understandings of medication communication in acute care hospital settings. Ethical issues of informed consent, patient safety and respect for the confidentiality of patients and clinicians need to be carefully addressed to build up and maintain trusting relationships between researchers and participants in the clinical environment. By prudently considering the complex ethical and methodological concerns of using video ethnography, this approach can help to reveal the unpredictability and messiness of clinical practice. The visual data generated can stimulate clinicians' reflexivity about their norms of practice and bring about improved communication about managing medications. © 2015 John Wiley & Sons Ltd.

An interdisciplinary approach to personalized medicine: case studies from a cardiogenetics clinic.

PubMed

Erskine, Kathleen E; Griffith, Eleanor; Degroat, Nicole; Stolerman, Marina; Silverstein, Louise B; Hidayatallah, Nadia; Wasserman, David; Paljevic, Esma; Cohen, Lilian; Walsh, Christine A; McDonald, Thomas; Marion, Robert W; Dolan, Siobhan M

2013-01-01

In the genomic age, the challenges presented by various inherited conditions present a compelling argument for an interdisciplinary model of care. Cardiac arrhythmias with a genetic basis, such as long QT syndrome, require clinicians with expertise in many specialties to address the complex genetic, psychological, ethical and medical issues involved in treatment. The Montefiore-Einstein Center for CardioGenetics has been established to provide personalized, interdisciplinary care for families with a history of sudden cardiac death or an acute cardiac event. Four vignettes of patient care are presented to illustrate the unique capacity of an interdisciplinary model to address genetic, psychological, ethical and medical issues. Because interdisciplinary clinics facilitate collaboration among multiple specialties, they allow for individualized, comprehensive care to be delivered to families who experience complex inherited medical conditions. As the genetic basis of many complex conditions is discovered, the advantages of an interdisciplinary approach for delivering personalized medicine will become more evident.

Medical Transport of Children with Complex Chronic Conditions

PubMed Central

Lerner, Carlos F.; Kelly, Robert B.; Hamilton, Leslie J.; Klitzner, Thomas S.

2012-01-01

One of the most notable trends in child health has been the increase in the number of children with special health care needs, including those with complex chronic conditions. Care of these children accounts for a growing fraction of health care resources. We examine recent developments in health care, especially with regard to medical transport and prehospital care, that have emerged to adapt to this remarkable demographic trend. One such development is the focus on care coordination, including the dissemination of the patient-centered medical home concept. In the prehospital setting, the need for greater coordination has catalyzed the development of the emergency information form. Training programs for prehospital providers now incorporate specific modules for children with complex conditions. Another notable trend is the shift to a family-centered model of care. We explore efforts toward regionalization of care, including the development of specialized pediatric transport teams, and conclude with recommendations for a research agenda. PMID:22315689

Early or delayed surgical treatment in compound limb fractures due to high velocity missile injuries: a 5-year retrospective study from Medical City in Baghdad.

PubMed

Al-Hilli, Ali Bakir; Salih, Dheyaa Saeed

2010-01-01

Compound limb fractures due to high-velocity missiles are complex and usually associated with multiple other injuries. These can occur in both military and civilian settings. High-velocity missiles are presently used by terrorists worldwide. Early surgical debridement and skeletal fixation are the gold standards in managing these injuries, but data supporting these recommendations are lacking. Our aim was to determine the relationship between time (the time of injury to the time of surgical treatment) and the rate of deep infection in patients treated in Medical City, Baghdad, Iraq due to terrorist activity from 2004-2008. This is a retrospective review of a series of open limb fractures. A total of 102 civilian patients with 114 limb fractures due to high-velocity missile injuries were selected for this study from Medical City records. Patients were followed in the outpatient department in Medical City Teaching Complex both clinically and radiologically. Surgical treatment was accomplished in less than six hours from time of injury in group A (55 fractures, 48.4%) and more than six hours in group B (59 fractures, 51.7%). The infection rate for group A was 30.9% and group B was 23.7%. A very high infection rate was noted for these injuries, and there was no increase in the rate of deep infection in patients treated more than six hours after the injury.

The sodium pentothal hypnosis interview with follow-up treatment for complex regional pain syndrome.

PubMed

Simon, E P; Dahl, L F

1999-08-01

A patient who was unresponsive to multiple conservative medical treatments for complex regional pain syndrome was assessed using a novel approach--the sodium pentothal hypnosis interview. The interview suggested that his pain was centrally generated. The patient's pain symptoms resolved with hypnotherapeutic treatment. Indications for this procedure and implications for assessment and treatment are discussed. This case raises more questions than it answers, and leaves the reader to struggle with current difficulties in diagnostic decision-making.

The complex legal and ethical issues related to generic medications. Viral hepatitis: a case study.

PubMed

Danta, M; Ghinea, N

2017-04-01

The economic impact of medications is significant, with many countries unable to afford the essential medicines listed by the WHO. Generic medications are one strategy to address this issue. Generic medications are similar to but not the same as originator medications. They have a significant cost advantage because they do not require the background research and development studies to support registration. Consequently, they are gaining increased market share in both the developed and developing world. Many new medications are now licensed to generic manufacturers in the developing world. As a result, it is possible for patients to bypass regulatory and cost barriers by importing medications directly from generic producers. Importation of the novel hepatitis C direct-acting antiviral therapy into Australia before it was registered in the country is an illustrative case study. This review will characterise generic medications and some of the legal and ethical issues around their utilisation, focusing on the relevant players, including pharma, government, patients and doctors.

Airway management through submental derivation: a safe and easily reproduced alternative for patients with complex facial trauma

PubMed Central

2018-01-01

Objectives Airway management in patients with panfacial trauma is complicated. In addition to involving facial lesions, such trauma compromises the airway, and the use of intermaxillary fixation makes it difficult to secure ventilation by usual approaches (nasotracheal or endotracheal intubation). Submental airway derivation is an alternative to tracheostomy and nasotracheal intubation, allowing a permeable airway with minimal complications in complex patients. Materials and Methods This is a descriptive, retrospective study based on a review of medical records of all patients with facial trauma from January 2003 to May 2015. In total, 31 patients with complex factures requiring submental airway derivation were included. No complications such as bleeding, infection, vascular, glandular, or nervous lesions were presented in any of the patients. Results The use of submental airway derivation is a simple, safe, and easy method to ensure airway management. Moreover, it allows an easier reconstruction. Conclusion Based on these results, we concluded that, if the relevant steps are followed, the use of submental intubation in the treatment of patients with complex facial trauma is a safe and effective option. PMID:29535964

Simple prescribing errors and allergy documentation in medical hospital admissions in Australia and New Zealand.

PubMed

Barton, Lorna; Futtermenger, Judith; Gaddi, Yash; Kang, Angela; Rivers, Jon; Spriggs, David; Jenkins, Paul F; Thompson, Campbell H; Thomas, Josephine S

2012-04-01

This study aimed to quantify and compare the prevalence of simple prescribing errors made by clinicians in the first 24 hours of a general medical patient's hospital admission. Four public or private acute care hospitals across Australia and New Zealand each audited 200 patients' drug charts. Patient demographics, pharmacist review and pre-defined prescribing errors were recorded. At least one simple error was present on the medication charts of 672/715 patients, with a linear relationship between the number of medications prescribed and the number of errors (r = 0.571, p < 0.001). The four sites differed significantly in the prevalence of different types of simple prescribing errors. Pharmacists were more likely to review patients aged > or = 75 years (39.9% vs 26.0%; p < 0.001) and those with more than 10 drug prescriptions (39.4% vs 25.7%; p < 0.001). Patients reviewed by a pharmacist were less likely to have inadequate documentation of allergies (13.5% vs 29.4%, p < 0.001). Simple prescribing errors are common, although their nature differs from site to site. Clinical pharmacists target patients with the most complex health situations, and their involvement leads to improved documentation.

Patient-oriented education and medication management intervention for people with decompensated cirrhosis: study protocol for a randomized controlled trial.

PubMed

Hayward, Kelly L; Martin, Jennifer H; Cottrell, W Neil; Karmakar, Antara; Horsfall, Leigh U; Patel, Preya J; Smith, David D; Irvine, Katharine M; Powell, Elizabeth E; Valery, Patricia C

2017-07-20

People with decompensated cirrhosis require complex medical care and are often prescribed an intricate and frequently changing medication and lifestyle regimen. However, many patients mismanage their medications or have poor comprehension of their disease and self-management tasks. This can lead to harm, hospitalization, and death. A patient-oriented education and medication management intervention has been developed for implementation at a tertiary hospital hepatology outpatient center in Queensland, Australia. Consenting patients with decompensated cirrhosis will be randomly allocated to education intervention or usual care treatment arms when they attend routine follow-up appointments. In the usual care arm, participants will be reviewed by their hepatologist according to the current model of care in the hepatology clinic. In the intervention arm, participants will be reviewed by a clinical pharmacist to receive the education and medication management intervention at baseline in addition to review by their hepatologist. Intervention participants will also receive three further educational contacts from the clinical pharmacist within the following 6-month period, in addition to routine hepatologist review that is scheduled within this time frame. All participants will be surveyed at baseline and follow-up (approximately 6 months post-enrollment). Validated questionnaire tools will be used to determine participant adherence, medication beliefs, illness perceptions, and quality of life. Patients' knowledge of dietary and lifestyle modifications, their current medications, and other clinical data will be obtained from the survey, patient interview, and medical records. Patient outcome data will be collected at 52 weeks. The intervention described within this protocol is ready to adapt and implement in hepatology ambulatory care centers globally. Investigation of potentially modifiable variables that may impact medication management, in addition to the effect of a clinical pharmacist-driven education and medication management intervention on modifying these variables, will provide valuable information for future management of these patients. Australian and New Zealand Clinical Trial Registry identifier: ACTRN12616000780459 . Registered on 15 June 2016.

WE-D-303-00: Computational Phantoms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lewis, John; Brigham and Women’s Hospital and Dana-Farber Cancer Institute, Boston, MA

2015-06-15

Modern medical physics deals with complex problems such as 4D radiation therapy and imaging quality optimization. Such problems involve a large number of radiological parameters, and anatomical and physiological breathing patterns. A major challenge is how to develop, test, evaluate and compare various new imaging and treatment techniques, which often involves testing over a large range of radiological parameters as well as varying patient anatomies and motions. It would be extremely challenging, if not impossible, both ethically and practically, to test every combination of parameters and every task on every type of patient under clinical conditions. Computer-based simulation using computationalmore » phantoms offers a practical technique with which to evaluate, optimize, and compare imaging technologies and methods. Within simulation, the computerized phantom provides a virtual model of the patient’s anatomy and physiology. Imaging data can be generated from it as if it was a live patient using accurate models of the physics of the imaging and treatment process. With sophisticated simulation algorithms, it is possible to perform virtual experiments entirely on the computer. By serving as virtual patients, computational phantoms hold great promise in solving some of the most complex problems in modern medical physics. In this proposed symposium, we will present the history and recent developments of computational phantom models, share experiences in their application to advanced imaging and radiation applications, and discuss their promises and limitations. Learning Objectives: Understand the need and requirements of computational phantoms in medical physics research Discuss the developments and applications of computational phantoms Know the promises and limitations of computational phantoms in solving complex problems.« less

The introduction of medical humanities in the undergraduate curriculum of Greek medical schools: challenge and necessity.

PubMed

Batistatou, A; Doulis, E A; Tiniakos, D; Anogiannaki, A; Charalabopoulos, K

2010-10-01

Medical humanities is a multidisciplinary field, consisting of humanities (theory of literature and arts, philosophy, ethics, history and theology), social sciences (anthropology, psychology and sociology) and arts (literature, theater, cinema, music and visual arts), integrated in the undergraduate curriculum of Medical schools. The aim of the present study is to discuss medical humanities and support the necessity of introduction of a medical humanities course in the curriculum of Greek medical schools. Through the relevant Pub-Med search as well as taking into account various curricula of medical schools, it is evident that medical education today is characterized by acquisition of knowledge and skills and development of medical values and attitudes. Clinical observation with the recognition of key data and patterns in the collected information, is crucial in the final medical decision, i.e. in the complex process, through which doctors accumulate data, reach conclusions and decide on therapy. All sciences included in medical humanities are important for the high quality education of future doctors. The practice of Medicine is in large an image-related science. The history of anatomy and art are closely related, already from the Renaissance time. Studies have shown that attendance of courses on art critics improves the observational skills of medical students. Literature is the source of information about the nature and source of human emotions and behavior and of narratives of illness, and increases imagination. Philosophy aids in the development of analytical and synthetical thinking. Teaching of history of medicine develops humility and aids in avoiding the repetition of mistakes of the past, and quite often raises research and therapeutic skepticism. The comprehension of medical ethics and professional deontology guides the patient-doctor relationship, as well as the relations between physicians and their colleagues. The Medical Humanities course, which is already integrated in the undergraduate curriculum of many medical schools of Europe, USA and Australia, includes lectures by experts and students presentations on the above-mentioned areas and could be offered, for a semester, during the first years. The aim of Medical Humanities course is the development of imagination and interpretation of data through analytical complex procedures, the development of skills of close observation and careful interpretation of the patient "language" and the enhancement of empathy for the patients, as well as the development of the physician-patient relationship and finally the conceptualization/construction of personal and professional values.

Cybersecurity vulnerabilities in medical devices: a complex environment and multifaceted problem

PubMed Central

Williams, Patricia AH; Woodward, Andrew J

2015-01-01

The increased connectivity to existing computer networks has exposed medical devices to cybersecurity vulnerabilities from which they were previously shielded. For the prevention of cybersecurity incidents, it is important to recognize the complexity of the operational environment as well as to catalog the technical vulnerabilities. Cybersecurity protection is not just a technical issue; it is a richer and more intricate problem to solve. A review of the factors that contribute to such a potentially insecure environment, together with the identification of the vulnerabilities, is important for understanding why these vulnerabilities persist and what the solution space should look like. This multifaceted problem must be viewed from a systemic perspective if adequate protection is to be put in place and patient safety concerns addressed. This requires technical controls, governance, resilience measures, consolidated reporting, context expertise, regulation, and standards. It is evident that a coordinated, proactive approach to address this complex challenge is essential. In the interim, patient safety is under threat. PMID:26229513

Cybersecurity vulnerabilities in medical devices: a complex environment and multifaceted problem.

PubMed

Williams, Patricia Ah; Woodward, Andrew J

2015-01-01

The increased connectivity to existing computer networks has exposed medical devices to cybersecurity vulnerabilities from which they were previously shielded. For the prevention of cybersecurity incidents, it is important to recognize the complexity of the operational environment as well as to catalog the technical vulnerabilities. Cybersecurity protection is not just a technical issue; it is a richer and more intricate problem to solve. A review of the factors that contribute to such a potentially insecure environment, together with the identification of the vulnerabilities, is important for understanding why these vulnerabilities persist and what the solution space should look like. This multifaceted problem must be viewed from a systemic perspective if adequate protection is to be put in place and patient safety concerns addressed. This requires technical controls, governance, resilience measures, consolidated reporting, context expertise, regulation, and standards. It is evident that a coordinated, proactive approach to address this complex challenge is essential. In the interim, patient safety is under threat.

Patient centric drug product design in modern drug delivery as an opportunity to increase safety and effectiveness.

PubMed

Stegemann, Sven

2018-06-01

The advances in drug delivery technologies have enabled pharmaceutical scientists to deliver a drug through various administration routes and optimize the drug release and absorption. The wide range of drug delivery systems and dosage forms represent a toolbox of technology for the development of pharmaceutical drug products but might also be a source of medication errors and nonadherence. Patient centric drug product development is being suggested as an important factor to increase therapeutic outcomes. Areas covered: Patients have impaired health and potentially disabilities and they are not medical or pharmaceutical experts but are requested to manage complex therapeutic regimens. As such the application of technology should also serve to reduce complexity, build on patients' intuition and ease of use. Patients form distinct populations based on the targeted disease, disease cluster or age group with specific characteristics or therapeutic contexts. Expert opinion: Establishing a target product and patient profile is essential to guide drug product design development. Including the targeted patient populations in the process is a prerequisite to achieve patient-centric pharmaceutical drug product design. Addressing the needs early on in the product design process, will create more universal design, avoiding the necessity for multiple product presentations to cover the different patient populations.

Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications.

PubMed

Pressman, Mark R

2007-02-01

Sleepwalking and related disorders are the result of factors that predispose, prime and precipitate episodes. In the absence of one or more of these factors sleepwalking is unlikely to occur. Predisposition to sleepwalking is based on genetic susceptibility and has a familial pattern. Priming factors include conditions and substances that increase slow wave sleep (SWS) or make arousal from sleep more difficult. These factors include sleep deprivation, alcohol, medications, situational stress and fever among others. The patient with a genetic predisposition to sleepwalking and with priming factors still requires a precipitating factor or trigger to set the sleepwalking episode in motion. Classical theories of sleepwalking were based primarily on case reports. Recently some of these theories have been tested in the sleep laboratory. Experimental sleep deprivation studies of sleepwalkers generally report an increase in complex behaviors during SWS, although one prominent study reported the opposite effect. However, the generally accepted theory that alcohol and medications can induce sleepwalking episodes remains entirely based on clinical and forensic case reports. Alleged cases of alcohol related sleepwalking often involve individuals lacking the generally accepted characteristics of sleepwalkers but with very high blood alcohol levels that could in and of itself account for complex behaviors noted without the presence of sleepwalking. Further, the effects of high levels of alcohol dramatically decrease SWS, a finding inconsistent with sleepwalking. Case reports of medication-related induction of apparent sleepwalking most often present a complex medical and psychiatric history associated with multiple medications. These patients often lack the clinical history and other criteria currently required for the diagnosis of sleepwalking. The medication-related behaviors may instead represent some other condition in an awake, but impaired patient. Sleep laboratory research has identified sleep disordered breathing, periodic leg movements, noise and touch among others as proximal triggers of sleepwalking episodes. Treatment of these triggers may result in resolution of sleepwalking without medication. Further sleep laboratory research is needed before experimental findings can be used for routine diagnostic and forensic purposes.

When systems fail: improving care through technology can create risk.

PubMed

Bagalio, Sharon A

2007-01-01

Emerging medical technology is transforming the care of the modern-day patient. Hospital performance and patient safety is improving, lowering professional liability and medical malpractice costs. This advanced technology affects not only diagnosis and treatment but also hospital productivity and revenue. However, it also exposes hospitals and medical personnel to a number of unforeseeable risks. This article examines ongoing efforts to improve patient safety through the use of technology, automation and complex systems operations. It discusses the importance of skilled negotiation when vying for technology contracts and the value of maintaining a reliable data center to support it. Technology risk exposure is now a reality. A hospital needs to know how to protect itself from cyber liability, business interruption, and data loss and theft by ensuring that there is adequate coverage.

Clinicians’ views on improving inter-organizational care transitions

PubMed Central

2013-01-01

Background Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased healthcare spending due to re-hospitalization or emergency room visits by patients. Little is known about care transitions from acute care to complex continuing care and rehabilitation settings. Thus, a qualitative study was undertaken to explore clinicians’ perceptions of strategies aimed at improving patient care transitions from acute care hospitals to complex continuing care and rehabilitation healthcare organizations. Methods A qualitative study using semi-structured interviews was conducted with clinicians employed at two selected healthcare facilities: an acute care hospital and a complex continuing care/rehabilitation organization, respectively. Analysis of the transcripts involved the creation of a coding schema using the content analyses outlined by Ryan and Bernard. In total, 31 interviews were conducted with clinicians at the participating study sites. Results Three themes emerged from the data to delineate what study participants described as strategies to ensure quality inter-organizational transitions of patients transferred from acute care to the complex continuing care and rehabilitation hospital. These themes are: 1) communicating more effectively; 2) being vigilant around the patients’ readiness for transfer and care needs; and 3) documenting more accurately and completely in the patient transfer record. Conclusion Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions. Of particular importance is the need to have a collective and collaborative approach amongst clinicians during the inter-organizational care transition process. Study findings also suggest that the written patient transfer record needs to be augmented with a verbal report whereby the receiving clinician has an opportunity to discuss with a clinician from the acute care hospital the patient’s status on discharge and plan of care. Integral to future research efforts is designing and testing out interventions to optimize inter-organizational care transitions and feedback loops for complex medical patients. PMID:23899326

Systems Medicine 2.0: potential benefits of combining electronic health care records with systems science models.

PubMed

Tillmann, Taavi; Gibson, Alexander R; Scott, Gregory; Harrison, Oliver; Dominiczak, Anna; Hanlon, Phil

2015-03-23

The global burden of disease is increasingly dominated by non-communicable diseases.These diseases are less amenable to curative and preventative interventions than communicable disease. This presents a challenge to medical practice and medical research, both of which are experiencing diminishing returns from increasing investment. Our aim was to (1) review how medical knowledge is generated, and its limitations, (2) assess the potential for emerging technologies and ideas to improve medical research, and (3) suggest solutions and recommendations to increase medical research efficiency on non-communicable diseases. We undertook an unsystematic review of peer-reviewed literature and technology websites. Our review generated the following conclusions and recommendations. (1) Medical knowledge continues to be generated in a reductionist paradigm. This oversimplifies our models of disease, rendering them ineffective to sufficiently understand the complex nature of non-communicable diseases. (2) Some of these failings may be overcome by adopting a "Systems Medicine" paradigm, where the human body is modeled as a complex adaptive system. That is, a system with multiple components and levels interacting in complex ways, wherein disease emerges from slow changes to the system set-up. Pursuing systems medicine research will require larger datasets. (3) Increased data sharing between researchers, patients, and clinicians could provide this unmet need for data. The recent emergence of electronic health care records (EHR) could potentially facilitate this in real-time and at a global level. (4) Efforts should continue to aggregate anonymous EHR data into large interoperable data silos and release this to researchers. However, international collaboration, data linkage, and obtaining additional information from patients will remain challenging. (5) Efforts should also continue towards "Medicine 2.0". Patients should be given access to their personal EHR data. Subsequently, online communities can give researchers the opportunity to ask patients for direct access to the patient's EHR data and request additional study-specific information. However, selection bias towards patients who use Web 2.0 technology may be difficult to overcome. Systems medicine, when combined with large-scale data sharing, has the potential to raise our understanding of non-communicable diseases, foster personalized medicine, and make substantial progress towards halting, curing, and preventing non-communicable diseases. Large-scale data amalgamation remains a core challenge and needs to be supported. A synthesis of "Medicine 2.0" and "Systems Science" concepts into "Systems Medicine 2.0" could take decades to materialize but holds much promise.

Dyshormonia Iatrogenica: crossroads of medicine, malpractice law, and professional ethics in clinical endocrinology.

PubMed

Goldberg, Philip A; Varriale, David J; Mercurio, Mark R

2012-01-01

To present 2 challenging cases of patients who request endocrine therapies that their physician considers to be outside of the standard of care. With these complex cases as a backdrop, we explore the constructs of medicine, malpractice law, and professional ethics that guide physicians' medical decision-making processes. These cases illustrate a common conundrum for clinical endocrinologists, who often find themselves struggling to balance patient satisfaction and well-being with generally accepted standards of medical care. From the perspective of a malpractice lawyer, we review the keys to limiting medicolegal liability, with emphasis on thorough documentation, informed consent, and effective doctor-patient communication. We then review the constructs of professional ethics that guide patient care, with emphasis on virtues of the "good physician," patients' right to self-determination, and paternalism. Finally, we explore some justifications for a compassionate physician to refuse a patient's desired treatment plan. In the end, we hope that this manuscript helps to facilitate best medical, legal, professional, and ethical practices of clinical endocrinology.

Medication communication during ward rounds on medical wards: Power relations and spatial practices.

PubMed

Liu, Wei; Manias, Elizabeth; Gerdtz, Marie

2013-03-01

Communication plays a crucial role in the management of medications. Ward rounds are sites where health professionals from different disciplines and patients come together to exchange medication information and make treatment decisions. This article examines power relations and spatial practices surrounding medication communication between patients and health professionals including doctors, nurses and pharmacists during ward rounds. Data were collected in two medical wards of a metropolitan teaching hospital in Melbourne, Australia. Data collection methods involved participant observations, field interviews, video-recordings, together with individual and group reflexive interviews. A critical discourse analysis was undertaken to identify the location sites where power relations were reproduced or challenged in ward rounds. Findings demonstrated that traditional medical hierarchies constructed the ways in which doctors communicated about medications during ward rounds. Nurses and pharmacists ventured into the ward round space by using the discourse of preparation and occupying a peripheral physical position. Doctors privileged the discourse of medication rationalization in their ward round discussions, competing with the discourse of inquiry taken up by patients and families. Ward rounds need to be restructured to provide opportunities for nurses and pharmacists to speak at dedicated times and in strategic locations. By critically reflecting upon the complex process of medication communication during ward rounds, greater opportunities exist for enhanced team communication among health professionals.

Turning Over Patient Turnover: An Ethnographic Study of Admissions, Discharges, and Transfers

PubMed Central

Mowinski Jennings, Bonnie; Sandelowski, Margarete; Boshamer, Cary C.; Higgins, Melinda K.

2014-01-01

The impact on nursing work of patient turnover (admissions, discharges, and transfers) became evident in an ethnographic study of turbulence. The patient turnover data were generated from extensive observations, 21 formal interviews, and a year of admission and discharge records on one medical and one surgical unit. Timing of turnover events on the two units differed, but on both units admissions typically interrupted workflow more than did discharges, clustered admissions were more disruptive than staggered admissions, and patient turnover during change of shift was more disruptive than during medication administration. Understanding the complexity of patient turnover will elucidate the work involved and improve the evidence base for nurse staffing, a key determinant of quality and safety of care. PMID:24242196

Inappropriate Use of Medication by Elderly, Polymedicated, or Multipathological Patients with Chronic Diseases

PubMed Central

Pérez-Jover, Virtudes; Carratala-Munuera, Concepción; Gil-Guillen, Vicente F.; Basora, Josep; Orozco-Beltrán, Domingo

2018-01-01

The growth of the aging population leads to the increase of chronic diseases, of the burden of multimorbility, and of the complexity polypharmacy. The prevalence of medication errors rises in patients with polypharmacy in primary care, and this is a major concern to healthcare systems. This study reviews the published literature on the inappropriate use of medicines in order to articulate recommendations on how to reduce it in chronic patients, particularly in those who are elderly, polymedicated, or multipathological. A systematic review of articles published from January 2000 to October 2015 was performed using MEDLINE, EMBASE, PsychInfo, Scopus, The Cochrane Library, and Index Medicus databases. We selected 80 studies in order to analyse the content that addressed the question under consideration. Our literature review found that half of patients know what their prescribed treatment is; that most of elderly people take five or more medications a day; that in elderly, polymedicated people, the probability of a medication error occurring is higher; that new tools have been recently developed to reduce errors; that elderly patients can understand written information but the presentation and format is an important factor; and that a high percentage of patients have remaining doubts after their visit. Thus, strategies based on the evidence should be applied in order to reduce medication errors. PMID:29439425

[Use of Simulated Pacients in Psychiatry].

PubMed

Corso, Silvia J Franco; Delgado, Marta Beatriz; Gómez-Restrepo, Carlos

2012-01-01

Scientific advances and the complexity of human knowledge generate a constant need for creating new tools intended to facilitate learning in an agreeable and lasting form. Simulated patients are one of such tools in medical education. Standardized or simulated patients are actors or people vigorously trained to represent a medical history or, if possible, specific physical findings with the purpose of using such representations as an educational and evaluating supplement in clinic practice. The use of simulated patients has been very well received, particularly in the psychiatric field; however, its usefulness in areas such as psychotherapy or evaluation of residents remains questionable. A search was made in PubMed with the MESH words ("Psychiatry/education" and "Patient Simulation"); a search was also made in LILACS and scholar Google using similar words. Simulated patients are widely used throughout the world in the psychiatry field and their usefulness as an academic tool for pre-graduate students is confirmed in most of the literature reviewed. One of the main benefits of the use of this kind of patients is the acquisition of specific abilities (e.g.: medical history recording); nevertheless, its efficacy in more complex experiences like psychotherapy or certification of psychiatry residents is questioned. Notwithstanding the controversy, most of the literature reviewed confirms the benefits and acceptance of this methodology in the formation of students and psychiatrists. Copyright © 2012 Asociación Colombiana de Psiquiatría. Publicado por Elsevier España. All rights reserved.

An Investigation of Drug-Drug Interaction Alert Overrides at a Pediatric Hospital.

PubMed

Humphrey, Kate; Jorina, Maria; Harper, Marvin; Dodson, Brenda; Kim, Seung-Yeon; Ozonoff, Al

2018-05-01

Drug-drug interactions (DDIs) can result in patient harm. DDI alerts are intended to help prevent harm; when the majority of alerts presented to providers are being overridden, their value is diminished. Our objective was to evaluate the overall rates of DDI alert overrides and how rates varied by specialty, clinician type, and patient complexity. A retrospective study of DDI alert overrides that occurred during 2012 and 2013 within the inpatient setting described at the medication-, hospital-, provider-, and patient encounter-specific levels was performed at an urban, quaternary-care, pediatric hospital. There were >41 000 DDI alerts presented to clinicians; ∼90% were overridden. The 5 DDI pairs that were most frequently presented and overridden included the following: potassium chloride-spironolactone, methadone-ondansetron, ketorolac-ibuprofen, cyclosporine-fluconazole, and potassium chloride-enalapril, each with an alert override rate of ≥0.89. Override rates across provider groups ranged between 0.84 and 0.97. In general, patients with high complexity had a higher frequency of alert overrides, but the rates of alert overrides for each DDI pairing did not differ significantly. High rates of DDI alert overrides occur across medications, provider groups, and patient encounters. Methods to decrease DDI alerts which are likely to be overridden exist, but it is also clear that more robust and intelligent tools are needed. Characteristics exist at the medication, hospital, provider, and patient levels that can be used to help specialize and enhance information transmission. Copyright © 2018 by the American Academy of Pediatrics.

Demonopolizing medical knowledge.

PubMed

Arora, Sanjeev; Thornton, Karla; Komaromy, Miriam; Kalishman, Summers; Katzman, Joanna; Duhigg, Daniel

2014-01-01

In the past 100 years, there has been an explosion of medical knowledge-and in the next 50 years, more medical knowledge will be available than ever before. Regrettably, current medical practice has been unable to keep pace with this explosion of medical knowledge. Specialized medical knowledge has been confined largely to academic medical centers (i.e., teaching hospitals) and to specialists in major cities; it has been disconnected from primary care clinicians on the front lines of patient care. To bridge this disconnect, medical knowledge must be demonopolized, and a platform for collaborative practice amongst all clinicians needs to be created. A new model of health care and education delivery called Project ECHO (Extension for Community Healthcare Outcomes), developed by the first author, does just this. Using videoconferencing technology and case-based learning, ECHO's medical specialists provide training and mentoring to primary care clinicians working in rural and urban underserved areas so that the latter can deliver the best evidence-based care to patients with complex health conditions in their own communities. The ECHO model increases access to care in rural and underserved areas, and it demonopolizes specialized medical knowledge and expertise.

[On the development of a system of medical weather forecast for the Caucasian Mineral Waters spa-and-resort complex].

PubMed

Povolotskaia, N P; Efimova, N V; Zherlitsina, L I; Kirilenko, A A; Kortunova, Z V; Golitsin, G S; Senik, I A; Rubinshteĭn, K G

2010-01-01

A system of medical weather forecast for the Caucasian Mineral Waters spa-and-resort complex has been modified and updated based on the results of long-term observations of weather conditions in the region of interest with special reference to the bioclimatic regime, atmospheric circulation, aerosol pollution of the near-ground air, ultraviolet radiation, heliomagnetic activity, and meteopathic effects. This system provides a basis for the timely emergency meteopreventive treatment of meteodependent patients and therefore can be instrumental in enhancing efficiency of spa-and-resort rehabilitative therapy.

Three-dimensional printing in congenital heart disease: A systematic review.

PubMed

Lau, Ivan; Sun, Zhonghua

2018-02-17

Three-dimensional (3D) printing has shown great promise in medicine with increasing reports in congenital heart disease (CHD). This systematic review aims to analyse the main clinical applications and accuracy of 3D printing in CHD, as well as to provide an overview of the software tools, time and costs associated with the generation of 3D printed heart models. A search of different databases was conducted to identify studies investigating the application of 3D printing in CHD. Studies based on patient's medical imaging datasets were included for analysis, while reports on in vitro phantom or review articles were excluded from the analysis. A total of 28 studies met selection criteria for inclusion in the review. More than half of the studies were based on isolated case reports with inclusion of 1-12 cases (61%), while 10 studies (36%) focused on the survey of opinion on the usefulness of 3D printing by healthcare professionals, patients, parents of patients and medical students, and the remaining one involved a multicentre study about the clinical value of 3D printed models in surgical planning of CHD. The analysis shows that patient-specific 3D printed models accurately replicate complex cardiac anatomy, improve understanding and knowledge about congenital heart diseases and demonstrate value in preoperative planning and simulation of cardiac or interventional procedures, assist surgical decision-making and intra-operative orientation, and improve patient-doctor communication and medical education. The cost of 3D printing ranges from USD 55 to USD 810. This systematic review shows the usefulness of 3D printed models in congenital heart disease with applications ranging from accurate replication of complex cardiac anatomy and pathology to medical education, preoperative planning and simulation. The additional cost and time required to manufacture the 3D printed models represent the limitations which need to be addressed in future studies. © 2018 The Authors. Journal of Medical Radiation Sciences published by John Wiley & Sons Australia, Ltd on behalf of Australian Society of Medical Imaging and Radiation Therapy and New Zealand Institute of Medical Radiation Technology.

Toxicologic Pathology Forum Opinion Paper: Considerations for Toxicologic Pathologists Evaluating the Safety of Biomaterials and Finished Medical Devices.

PubMed

Gad, Shayne C; Schuh, JoAnn C L

2018-06-01

Safety ("biocompatibility") assessment of medical devices has evolved along a different path than that of drugs, being historically governed more by the considerations and needs of engineers rather than chemists and biologists. As a result, the involvement of veterinary pathologists has been much more limited-almost entirely to evaluating tissue responses in tissues in direct contact with implanted devices. As devices have become more complex in composition, structure, placement, and use, concerns as to adverse systemic responses in patients have called for more comprehensive and thoughtful evaluations of effects throughout the body. Further complexities arise from the increasing marriage of devices and drug/biologic therapeutics to achieve either better dose control and, specifically, in delivery to target organs/tissues or better tolerance of the body to medical devices (i.e., minimization of the foreign body response). The challenge to pathologists is to integrate in new technologies (such as in vivo imaging and immunology) and ways of viewing interactions with patient bodies. To fail to do so will allow the methods and standards for medical device safety evaluation to be based on chemical analysis and then the limited details inherent in literature-based risk assessments.

A Remote Medication Monitoring System for Chronic Heart Failure Patients to Reduce Readmissions: A Two-Arm Randomized Pilot Study.

PubMed

Hale, Timothy M; Jethwani, Kamal; Kandola, Manjinder Singh; Saldana, Fidencio; Kvedar, Joseph C

2016-04-17

Heart failure (HF) is a chronic condition affecting nearly 5.7 million Americans and is a leading cause of morbidity and mortality. With an aging population, the cost associated with managing HF is expected to more than double from US $31 billion in 2012 to US $70 billion by 2030. Readmission rates for HF patients are high-25% are readmitted at 30 days and nearly 50% at 6 months. Low medication adherence contributes to poor HF management and higher readmission rates. Remote telehealth monitoring programs aimed at improved medication management and adherence may improve HF management and reduce readmissions. The primary goal of this randomized controlled pilot study is to compare the MedSentry remote medication monitoring system versus usual care in older HF adult patients who recently completed a HF telemonitoring program. We hypothesized that remote medication monitoring would be associated with fewer unplanned hospitalizations and emergency department (ED) visits, increased medication adherence, and improved health-related quality of life (HRQoL) compared to usual care. Participants were randomized to usual care or use of the remote medication monitoring system for 90 days. Twenty-nine participants were enrolled and the final analytic sample consisted of 25 participants. Participants completed questionnaires at enrollment and closeout to gather data on medication adherence, health status, and HRQoL. Electronic medical records were reviewed for data on baseline classification of heart function and the number of unplanned hospitalizations and ED visits during the study period. Use of the medication monitoring system was associated with an 80% reduction in the risk of all-cause hospitalization and a significant decrease in the number of all-cause hospitalization length of stay in the intervention arm compared to usual care. Objective device data indicated high adherence rates (95%-99%) among intervention group participants despite finding no significant difference in self-reported adherence between study arms. The intervention group had poorer heart function and HRQoL at baseline, and HRQoL declined significantly in the intervention group compared to controls. The MedSentry medication monitoring system is a promising technology that merits continued development and evaluation. The MedSentry medication monitoring system may be useful both as a standalone system for patients with complex medication regimens or used to complement existing HF telemonitoring interventions. We found significant reductions in risk of all-cause hospitalization and the number of all-cause length of stay in the intervention group compared to controls. Although HRQoL deteriorated significantly in the intervention group, this may have been due to the poorer HF-functioning at baseline in the intervention group compared to controls. Telehealth medication adherence technologies, such as the MedSentry medication monitoring system, are a promising method to improve patient self-management,the quality of patient care, and reduce health care utilization and expenditure for patients with HF and other chronic diseases that require complex medication regimens. ClinicalTrials.gov NCT01814696; https://clinicaltrials.gov/ct2/show/study/NCT01814696 (Archived by WebCite® at http://www.webcitation.org/6giqAVhno).

Medical student, nursing student, and non-health care respondents' implicit attitudes toward doctors and patients: Development and a pilot study of a new implicit attitudes test (IAT).

PubMed

Schwartz, Alan; Mazouni, Abdelhamid

2017-01-01

Medical educators have been concerned that medical students may decline in empathy for patients during the course of their training, based on studies measuring clinical empathy using psychometrically strong self-report measures. Clinical empathy is a complex construct, incorporating attitudes toward patients but also other components, such as professional detachment. Triangulation of extant measures with instruments based on nonreactive methods could provide a better understanding of whether and how physician attitudes toward patients may be changing during training. We sought to develop and pilot-test such a nonreactive method. We develop variations of an implicit association test (IAT) designed to measure attitudes toward physicians and patients based on speed of reaction to images of actors and positive and negative words. In the IATs, the same actors are photographed as doctors, clinic outpatients, hospitalized inpatients, and as a "general public" control. We examine preliminary evidence for their validity by collecting pilot data from internet participants (not involved in the health professions), medical students, and nursing students. Internet participants (n = 314) and nursing students (n = 31) had more negative associations (IAT scores) with doctors than did medical students (n = 89); nursing students and female internet participants had more positive associations with hospitalized patients than did medical students and male internet participants. Medical students' associations with hospitalized patients varied by year of training. This IAT may provide insight into implicit attitudes among those who enter training for the health profession and changes in those attitudes that may be inculcated during that training.

Frequency, Expected Effects, Obstacles, and Facilitators of Disclosure of Patient Safety Incidents: A Systematic Review

PubMed Central

2017-01-01

Objectives We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI). Methods We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them. Results There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI. Conclusions The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required. PMID:28372351

Improving Post-Discharge Medication Adherence in Patients with CVD: A Pilot Randomized Trial

PubMed Central

Oliveira-Filho, Alfredo D.; Morisky, Donald E.; Costa, Francisco A.; Pacheco, Sara T.; Neves, Sabrina F.; Lyra-Jr, Divaldo P.

2014-01-01

Background Effective interventions to improve medication adherence are usually complex and expensive. Objective To assess the impact of a low-cost intervention designed to improve medication adherence and clinical outcomes in post-discharge patients with CVD. Method A pilot RCT was conducted at a teaching hospital. Intervention was based on the four-item Morisky Medication Adherence Scale (MMAS-4). The primary outcome measure was medication adherence assessed using the eight-item MMAS at baseline, at 1 month post hospital discharge and re-assessed 1 year after hospital discharge. Other outcomes included readmission and mortality rates. Results 61 patients were randomized to intervention (n = 30) and control (n = 31) groups. The mean age of the patients was 61 years (SD 12.73), 52.5% were males, and 57.4% were married or living with a partner. Mean number of prescribed medications per patient was 4.5 (SD 3.3). Medication adherence was correlated to intervention (p = 0.04) and after 1 month, 48.4% of patients in the control group and 83.3% in the intervention group were considered adherent. However, this difference decreased after 1 year, when adherence was 34.8% and 60.9%, respectively. Readmission and mortality rates were related to low adherence in both groups. Conclusion The intervention based on a validated patient self-report instrument for assessing adherence is a potentially effective method to improve adherent behavior and can be successfully used as a tool to guide adherence counseling in the clinical visit. However, a larger study is required to assess the real impact of intervention on these outcomes. PMID:25590930

Avianca flight No. 052 accident: a plastic surgical perspective.

PubMed

Greenberg, B M; Brewer, B W

1991-09-01

The crash of Avianca Airlines flight no. 052 en route to JFK Airport on January 25, 1990, in Cove Neck, New York, resulted in the death of 72 passengers. Eighty-nine victims were admitted to 13 regional hospitals. Despite difficult access to the wooded crash site, early warning and prompt response by 37 volunteer fire and rescue units resulted in organized EMS triage and rapid hospital transport. This report reviews the specific injuries incurred, highlights the team management approach to a major aviation accident in a suburban area, and studies the likelihood of accidents of this magnitude. Thirty-eight patients triaged to two level I trauma centers, North Shore University Hospital-Cornell University Medical Center and Nassau County Medical Center, form the basis of this report. Seventeen patients were male; 21 were female. The average patient age was 33 years. Eight patients were children. The average length of stay was 30.9 days (range 2 to greater than 90 days). Twenty-six patients (including nonsurvivors) (68 percent) sustained significant multiple orthopedic injuries. The majority of fractures were open grade II to III tibia-fibula fractures. Bilaterality was commonly seen. Soft-tissue coverage of open long bone fractures was required in 10 patients (11 extremities) and included 3 microvascular muscle transfers, 7 muscle transposition flaps, and 3 skin grafts. Seven patients required open reduction and fixation of complex facial fractures (two of Le Fort II to III type, four of complex naso-orbital-ethmoid type). Plastic surgical repair of complex lacerations was common. Peripheral nerve exploration was required in three patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Medication-related clinical decision support in computerized provider order entry systems: a review.

PubMed

Kuperman, Gilad J; Bobb, Anne; Payne, Thomas H; Avery, Anthony J; Gandhi, Tejal K; Burns, Gerard; Classen, David C; Bates, David W

2007-01-01

While medications can improve patients' health, the process of prescribing them is complex and error prone, and medication errors cause many preventable injuries. Computer provider order entry (CPOE) with clinical decision support (CDS), can improve patient safety and lower medication-related costs. To realize the medication-related benefits of CDS within CPOE, one must overcome significant challenges. Healthcare organizations implementing CPOE must understand what classes of CDS their CPOE systems can support, assure that clinical knowledge underlying their CDS systems is reasonable, and appropriately represent electronic patient data. These issues often influence to what extent an institution will succeed with its CPOE implementation and achieve its desired goals. Medication-related decision support is probably best introduced into healthcare organizations in two stages, basic and advanced. Basic decision support includes drug-allergy checking, basic dosing guidance, formulary decision support, duplicate therapy checking, and drug-drug interaction checking. Advanced decision support includes dosing support for renal insufficiency and geriatric patients, guidance for medication-related laboratory testing, drug-pregnancy checking, and drug-disease contraindication checking. In this paper, the authors outline some of the challenges associated with both basic and advanced decision support and discuss how those challenges might be addressed. The authors conclude with summary recommendations for delivering effective medication-related clinical decision support addressed to healthcare organizations, application and knowledge base vendors, policy makers, and researchers.

Postoperative pain management techniques in hip and knee arthroplasty.

PubMed

Parvizi, Javad; Porat, Manny; Gandhi, Kishor; Viscusi, Eugene R; Rothman, Richard H

2009-01-01

Adequate control of postoperative pain following hip and knee arthroplasty can be a challenging task fraught with potential complications. Postoperative pain is perceived by the patient via a complex network and a multitude of molecular messengers in both the peripheral and central nervous systems. This allows the physician to modulate pain via an array of medications that act on different sites within the body. Using both contemporary and traditional pain modulators, the delivery and timing of these medications can affect postoperative pain and, ultimately, rehabilitation of the arthroplasty patient. Current techniques for controlling pain use both multimodal and preemptive analgesia to improve the outcome of the surgery while minimizing the potential adverse effects of the medications given.

Long term results of diode laser cycloablation in complex glaucoma using the Zeiss Visulas II system

PubMed Central

Ataullah, S; Biswas, S; Artes, P H; O'Donoghue, E; Ridgway, A E A; Spencer, A F

2002-01-01

Aim: To investigate the safety and efficacy of the Zeiss Visulas II diode laser system in the reduction of intraocular pressure (IOP) in patients with complex glaucoma. Methods: The authors analysed the medical records of patients who underwent trans-scleral diode laser cycloablation (TDC) at the Manchester Royal Eye Hospital during a 34 month period. 55 eyes of 53 patients with complex glaucoma were followed up for a period of 12–52 months (mean 23.1 months) after initial treatment with the Zeiss Visulas II diode laser system. Results: Mean pretreatment IOP was 35.8 mm Hg (range 22–64 mm Hg). At the last examination, mean IOP was 17.3 mm Hg (range 0–40 mm Hg). After treatment, 45 eyes (82%) had an IOP between 5 and 22 mm Hg; in 46 eyes (84%) the preoperative IOP had been reduced by 30% or more. The mean number of treatment sessions was 1.7 (range 1–6). At the last follow up appointment, the mean number of glaucoma medications was reduced from 2.1 to 1.6 (p<0.05). In 10 eyes (18%), post-treatment visual acuity (VA) was worse than pretreatment VA by 2 or more lines. Conclusions: Treatment with the Zeiss Visulas II diode laser system can be safely repeated in order to achieve the target IOP. Treatment outcomes in this study were similar to those from previously published work using the Iris Medical Oculight SLx laser. PMID:11801501

Improving the Medical Curriculum in Predoctoral Dental Education: Recommendations From the American Association of Oral and Maxillofacial Surgeons Committee on Predoctoral Education and Training.

PubMed

Dennis, Matthew J; Bennett, Jeffrey D; DeLuke, Dean M; Evans, Erik W; Hudson, John W; Nattestad, Anders; Ness, Gregory M; Yeung, Allison

2017-02-01

Dental procedures are often performed on patients who present with some level of medical fragility. In many dental schools, the exercise of taking a medical history is all too often a transcription of information to the dental chart, with little emphasis on the presurgical risk assessment and the development of a treatment plan appropriate to the medical status of the dental patient. Changes in dentistry, driven by an increasingly medically complex population of dental patients, combined with treatment advances rooted in the biomedical sciences necessitate the adaptation of our dental education to include a stronger background in systemic health. Many predoctoral educators in the American Association of Oral and Maxillofacial Surgeons (AAOMS) have expressed concern about the medical preparedness of our dental students; therefore, the AAOMS and its Committee on Predoctoral Education and Training have provided recommendations for improving the medical curriculum in predoctoral dental education, including a strengthening of training in clinical medicine and biomedical sciences, with specific recommendations for improved training of our dental students and dental faculty. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Medication administration via enteral feeding tube: a survey of pharmacists' knowledge.

PubMed

Joos, Elke; Verbeke, Stacey; Mehuys, Els; Van Bocxlaer, Jan; Remon, Jean Paul; Van Winckel, Myriam; Boussery, Koen

2016-02-01

Medication administration to patients with an enteral feeding tube (EFT) is complex and prone to errors. Community pharmacists may be ideally placed to provide training and advice on this topic in individual patients as well as in institutions supplied by the pharmacy. To assess community pharmacists’ knowledge on guideline recommendations regarding medication preparation and administration through EFT. Knowledge of guideline recommendations was assessed using a 15-item self-administered online questionnaire (April–June 2014). Questions reflected key aspects of guideline recommendations on medication administration via EFT. All graduated community pharmacists from the Dutch-speaking part of Belgium were eligible for participation. A total of 105 community pharmacists completed the questionnaire. Median self-perceived knowledge of medication administration via EFT was 2 (on a 0–10 scale). On average 5.2 (SD 2.6) out of the 15 questions were answered correctly. Strikingly, the ability to select suspensions in a list of liquid medications and knowledge on crushability of solid dosage forms were low. Our findings demonstrate that pharmacists’ knowledge on correct medication administration via EFT is too limited to be able to provide good advice to EFT patients or their caregivers. Tailored training on this topic is needed.

Protocol for a realist review of workplace learning in postgraduate medical education and training.

PubMed

Wiese, Anel; Kilty, Caroline; Bergin, Colm; Flood, Patrick; Fu, Na; Horgan, Mary; Higgins, Agnes; Maher, Bridget; O'Kane, Grainne; Prihodova, Lucia; Slattery, Dubhfeasa; Bennett, Deirdre

2017-01-19

Postgraduate medical education and training (PGMET) is a complex social process which happens predominantly during the delivery of patient care. The clinical learning environment (CLE), the context for PGMET, shapes the development of the doctors who learn and work within it, ultimately impacting the quality and safety of patient care. Clinical workplaces are complex, dynamic systems in which learning emerges from non-linear interactions within a network of related factors and activities. Those tasked with the design and delivery of postgraduate medical education and training need to understand the relationship between the processes of medical workplace learning and these contextual elements in order to optimise conditions for learning. We propose to conduct a realist synthesis of the literature to address the overarching questions; how, why and in what circumstances do doctors learn in clinical environments? This review is part of a funded projected with the overall aim of producing guidelines and recommendations for the design of high quality clinical learning environments for postgraduate medical education and training. We have chosen realist synthesis as a methodology because of its suitability for researching complexity and producing answers useful to policymakers and practitioners. This realist synthesis will follow the steps and procedures outlined by Wong et al. in the RAMESES Publication Standards for Realist Synthesis and the Realist Synthesis RAMESES Training Materials. The core research team is a multi-disciplinary group of researchers, clinicians and health professions educators. The wider research group includes experts in organisational behaviour and human resources management as well as the key stakeholders; doctors in training, patient representatives and providers of PGMET. This study will draw from the published literature and programme, and substantive, theories of workplace learning, to describe context, mechanism and outcome configurations for PGMET. This information will be useful to policymakers and practitioners in PGMET, who will be able to apply our findings within their own contexts. Improving the quality of clinical learning environments can improve the performance, humanism and wellbeing of learners and improve the quality and safety of patient care. The review is not registered with the PROSPERO International Prospective Register of Systematic Reviews as the review objectives relate solely to education outcomes.

Mobile technology supporting trainee doctors' workplace learning and patient care: an evaluation.

PubMed

Hardyman, Wendy; Bullock, Alison; Brown, Alice; Carter-Ingram, Sophie; Stacey, Mark

2013-01-21

The amount of information needed by doctors has exploded. The nature of knowledge (explicit and tacit) and processes of knowledge acquisition and participation are complex. Aiming to assist workplace learning, Wales Deanery funded "iDoc", a project offering trainee doctors a Smartphone library of medical textbooks. Data on trainee doctors' (Foundation Year 2) workplace information seeking practice was collected by questionnaire in 2011 (n = 260). iDoc baseline questionnaires (n = 193) collected data on Smartphone usage alongside other workplace information sources. Case reports (n = 117) detail specific instances of Smartphone use. Most frequently (daily) used information sources in the workplace: senior medical staff (80% F2 survey; 79% iDoc baseline); peers (70%; 58%); and other medical/nursing team staff (53% both datasets). Smartphones were used more frequently by males (p < 0.01). Foundation Year 1 (newly qualified) was judged the most useful time to have a Smartphone library because of increased responsibility and lack of knowledge/experience.Preferred information source varied by question type: hard copy texts for information-based questions; varied resources for skills queries; and seniors for more complex problems. Case reports showed mobile technology used for simple (information-based), complex (problem-based) clinical questions and clinical procedures (skills-based scenarios). From thematic analysis, the Smartphone library assisted: teaching and learning from observation; transition from medical student to new doctor; trainee doctors' discussions with seniors; independent practice; patient care; and this 'just-in-time' access to reliable information supported confident and efficient decision-making. A variety of information sources are used regularly in the workplace. Colleagues are used daily but seniors are not always available. During transitions, constant access to the electronic library was valued. It helped prepare trainee doctors for discussions with their seniors, assisting the interchange between explicit and tacit knowledge.By supporting accurate prescribing and treatment planning, the electronic library contributed to enhanced patient care. Trainees were more rapidly able to medicate patients to reduce pain and more quickly call for specific assessments. However, clinical decision-making often requires dialogue: what Smartphone technology can do is augment, not replace, discussion with their colleagues in the community of practice.

Insight, psychopathology, explanatory models and outcome of schizophrenia in India: a prospective 5-year cohort study.

PubMed

Johnson, Shanthi; Sathyaseelan, Manoranjitham; Charles, Helen; Jeyaseelan, Visalakshi; Jacob, Kuruthukulangara Sebastian

2012-09-27

The sole focus of models of insight on bio-medical perspectives to the complete exclusion of local, non-medical and cultural constructs mandates review. This study attempted to investigate the impact of insight, psychopathology, explanatory models of illness on outcome of first episode schizophrenia. Patients diagnosed to have DSM IV schizophrenia (n = 131) were assessed prospectively for insight, psychopathology, explanatory models of illness at baseline, 6, 12 and 60 months using standard instruments. Multiple linear and logistic regression and generalized estimating equations (GEE) were employed to assess predictors of outcome. We could follow up 95 (72.5%) patients. Sixty-five of these patients (68.4%) achieved remission. There was a negative relationship between psychosis rating and insight scores. Urban residence, fluctuating course of the initial illness, and improvement in global functioning at 6 months and lower psychosis rating at 12 months were significantly related to remission at 5 years. Insight scores, number of non-medical explanatory models and individual explanatory models held during the later course of the illness were significantly associated with outcome. Analysis of longitudinal data using GEE showed that women, rural residence, insight scores and number of non-medical explanatory models of illness held were significantly associated with BPRS scores during the study period. Insight, the disease model and the number of non-medical model positively correlated with improvement in psychosis arguing for a complex interaction between the culture, context and illness variables. These finding argue that insight and explanatory models are secondary to psychopathology, course and outcome of the illness. The awareness of mental illness is a narrative act in which people make personal sense of the many challenges they face. The course and outcome of the illness, cultural context, acceptable cultural explanations and the prevalent social stigma interact to produce a complex and multifaceted understanding of the issues. This complexity calls for a nuanced framing of insight.

Designing High Fidelity Simulation to Maximize Student Registered Nursing Decision-Making Ability

ERIC Educational Resources Information Center

Deckers, Cathleen

2011-01-01

The current healthcare environment is a complex system of patients, procedures, and equipment that strives to deliver safe and effective medical care. High fidelity simulation provides healthcare educators with a tool to create safety conscious practitioners utilizing an environment that replicates practice without risk to patients. Using HFS…

The Challenge of Managing Psoriasis: Unmet Medical Needs and Stakeholder Perspectives.

PubMed

Feldman, Steven R; Goffe, Bernard; Rice, Gary; Mitchell, Matthew; Kaur, Mandeep; Robertson, Debbie; Sierka, Debra; Bourret, Jeffrey A; Evans, Tamara S; Gottlieb, Alice

2016-12-01

Psoriasis is a debilitating chronic inflammatory autoimmune disease affecting approximately 7.4 million adults in the United States. Plaque psoriasis is the most common form, affecting 80% to 90% of patients. To describe the impact and challenges that psoriasis presents for various stakeholders, and to provide nondermatologist healthcare decision makers with information to enhance their contributions to drug and pharmacy benefit design discussions. Psoriasis carries an increased risk for early mortality and an increased prevalence of comorbidities, including psoriatic arthritis, cardiovascular disease, and diabetes. It is also associated with anxiety, depression, and social isolation, and can negatively impact patients' relationships, productivity, and careers. The physical, psychologic, social, and economic impact of psoriasis, plus the associated stigma, result in cumulative impairment over a patient's lifetime. The current treatments for moderate-to-severe psoriasis include topical therapy, phototherapy, and systemic drugs (nonbiologic and biologic); however, patient satisfaction remains low, combination therapy and treatment switching are common, and many patients remain untreated or undertreated. Clinicians should consider the patient holistically, and should select treatment based on a range of factors, including disease severity (with physical and psychosocial manifestations), susceptibility to cumulative life-course impairment (considering personality, behavior, and cognition), comorbidities, concomitant medication, and patient preference. It is estimated that the total annual direct cost of treating psoriasis in the United States in 2015 exceeded $12.2 billion. Psoriasis is a complex disease, and appropriate management is correspondingly complex. Newer psoriasis treatments provide improved efficacy and safety versus traditional treatments, but challenges remain in ensuring patients access to these medications. An improved understanding of the barriers to appropriate treatment is needed, as well as clear and accessible information for payers and clinicians on current treatment options, to ensure that decision makers can control costs while providing patients with optimal care.

Beyond prevalence to process: the role of self and identity in medical student well-being.

PubMed

Mavor, Kenneth I; McNeill, Kathleen G; Anderson, Katrina; Kerr, Annelise; O'Reilly, Erin; Platow, Michael J

2014-04-01

Problematic stress levels among medical students have been well established. This stress can lead to depression, suicidal ideation, substance abuse, burnout and cynicism, having a negative effect on students and their patients. We propose to move towards examining the processes underlying well-being in some medical students and vulnerability in others. We draw upon social psychological literature to propose that self-complexity, medical student identity and associated norms all have the capacity to influence medical students' well-being in both positive and negative ways. We identify two key dilemmas facing medical students with regard to the social psychological factors investigated. First, a diverse set of interests and a high level of self-complexity is thought to buffer against the effects of stress and might also be beneficial for medical practitioners, but the intensive nature of medical education makes it difficult for students to pursue outside interests, leading to a strongly focused identity. Second, a strong group identity is associated with high levels of social support and improved well-being, but unhealthy group norms may have a greater influence on individuals who have a strong group identity, encouraging them to engage in behaviours that place their well-being at risk. A model is proposed outlining how these potentially contradictory social psychological processes may combine to impact upon medical students' well-being. There is great scope for investigating the role of self-complexity, identity and norms in the medical education context, with room to investigate each of these factors alone and in combination. We highlight how our proposed model can inform medical educators as to the students who may be most vulnerable to the effects of stress and the potential interventions from which they may benefit. We conclude that social psychological factors make a valuable contribution to understanding the complex issue of well-being in medical education. © 2014 John Wiley & Sons Ltd.

Ethics seminars: a best-practice approach to navigating the against-medical-advice discharge.

PubMed

Clark, Mark A; Abbott, Jean T; Adyanthaya, Tara

2014-09-01

Patients who sign out or choose to leave the emergency department (ED) against medical advice (AMA) present important challenges. The current approach to the complex legal, ethical, and medical challenges that arise when adult patients decline medical care in the ED would benefit from a systematic best-practice strategy to maximize patient care outcomes, minimize legal risk, and reach the optimal ethical standard for this at-risk population. Professional responsibilities generated during an AMA encounter include determination of patient decision-making capacity, balancing protection of patient autonomy with prevention of harm, providing the best alternatives for patients who decline some or all of the proposed plan, negotiating to encourage patients to stay, planning for subsequent care, and documenting what transpired. We present two cases that illustrate key insights into a best-practice approach for emergency physicians (EPs) to address problems arising when patients want or need to leave the ED prior to completion of their care. We propose a practical, systematic framework, "AIMED" (assess, investigate, mitigate, explain, and document), that can be consistently applied in situations where patients consider leaving or do leave before their evaluations and urgent treatment are complete. Our goal is to maximize patient outcomes, minimize legal risk, and encourage a consistent and ethical approach to these vulnerable patients. © 2014 by the Society for Academic Emergency Medicine.

Understanding the value of mixed methods research: the Children’s Safety Initiative-Emergency Medical Services

PubMed Central

Hansen, Matthew; O’Brien, Kerth; Meckler, Garth; Chang, Anna Marie; Guise, Jeanne-Marie

2016-01-01

Mixed methods research has significant potential to broaden the scope of emergency care and specifically emergency medical services investigation. Mixed methods studies involve the coordinated use of qualitative and quantitative research approaches to gain a fuller understanding of practice. By combining what is learnt from multiple methods, these approaches can help to characterise complex healthcare systems, identify the mechanisms of complex problems such as medical errors and understand aspects of human interaction such as communication, behaviour and team performance. Mixed methods approaches may be particularly useful for out-of-hospital care researchers because care is provided in complex systems where equipment, interpersonal interactions, societal norms, environment and other factors influence patient outcomes. The overall objectives of this paper are to (1) introduce the fundamental concepts and approaches of mixed methods research and (2) describe the interrelation and complementary features of the quantitative and qualitative components of mixed methods studies using specific examples from the Children’s Safety Initiative-Emergency Medical Services (CSI-EMS), a large National Institutes of Health-funded research project conducted in the USA. PMID:26949970

Construction of suicidal ideation in medical records.

PubMed

Galasiński, Dariusz; Ziółkowska, Justyna

2017-09-01

In this article, the authors are interested in exploring discursive transformation of patients' stories of suicidal ideation into medical discourses. In other words, they focus on how the narrated experience of suicidal thoughts made during the psychiatric assessment interview is recorded in the patients' medical record. The authors' data come from recordings of psychiatric interviews, as well as the doctors' notes in the medical records made after the interviews, collected in psychiatric hospitals in Poland. Assuming a constructionist view of discourse, they demonstrate that lived experience of suicide ideation resulting in stories of a complex and homogeneous group of "thoughts" is reduced to brief statements of fact of presence/existence. Exploration of the relationship between the interviews and the notes suggest a stark imposition of the medical gaze upon them. The authors end with arguments that discursive practices relegating lived experience from the focus of clinical practice deprives it of information which is meaningful and clinically significant.

Clinical value of patient-specific three-dimensional printing of congenital heart disease: Quantitative and qualitative assessments

PubMed Central

Lau, Ivan Wen Wen; Liu, Dongting; Xu, Lei; Fan, Zhanming

2018-01-01

Objective Current diagnostic assessment tools remain suboptimal in demonstrating complex morphology of congenital heart disease (CHD). This limitation has posed several challenges in preoperative planning, communication in medical practice, and medical education. This study aims to investigate the dimensional accuracy and the clinical value of 3D printed model of CHD in the above three areas. Methods Using cardiac computed tomography angiography (CCTA) data, a patient-specific 3D model of a 20-month-old boy with double outlet right ventricle was printed in Tango Plus material. Pearson correlation coefficient was used to evaluate correlation of the quantitative measurements taken at analogous anatomical locations between the CCTA images pre- and post-3D printing. Qualitative analysis was conducted by distributing surveys to six health professionals (two radiologists, two cardiologists and two cardiac surgeons) and three medical academics to assess the clinical value of the 3D printed model in these three areas. Results Excellent correlation (r = 0.99) was noted in the measurements between CCTA and 3D printed model, with a mean difference of 0.23 mm. Four out of six health professionals found the model to be useful in facilitating preoperative planning, while all of them thought that the model would be invaluable in enhancing patient-doctor communication. All three medical academics found the model to be helpful in teaching, and thought that the students will be able to learn the pathology quicker with better understanding. Conclusion The complex cardiac anatomy can be accurately replicated in flexible material using 3D printing technology. 3D printed heart models could serve as an excellent tool in facilitating preoperative planning, communication in medical practice, and medical education, although further studies with inclusion of more clinical cases are needed. PMID:29561912

Long-Term Opioid Contract Use for Chronic Pain Management in Primary Care Practice. A Five Year Experience

PubMed Central

Lamb, Geoffrey C.; Neuner, Joan M.

2007-01-01

Background The use of opioid medications to manage chronic pain is complex and challenging, especially in primary care settings. Medication contracts are increasingly being used to monitor patient adherence, but little is known about the long-term outcomes of such contracts. Objective To describe the long-term outcomes of a medication contract agreement for patients receiving opioid medications in a primary care setting. Design Retrospective cohort study. Subjects All patients placed on a contract for opioid medication between 1998 and 2003 in an academic General Internal Medicine teaching clinic. Measurements Demographics, diagnoses, opiates prescribed, urine drug screens, and reasons for contract cancellation were recorded. The association of physician contract cancellation with patient factors and medication types were examined using the Chi-square test and multivariate logistic regression. Results A total of 330 patients constituting 4% of the clinic population were placed on contracts during the study period. Seventy percent were on indigent care programs. The majority had low back pain (38%) or fibromyalgia (23%). Contracts were discontinued in 37%. Only 17% were cancelled for substance abuse and noncompliance. Twenty percent discontinued contract voluntarily. Urine toxicology screens were obtained in 42% of patients of whom 38% were positive for illicit substances. Conclusions Over 60% of patients adhered to the contract agreement for opioids with a median follow-up of 22.5 months. Our experience provides insight into establishing a systematic approach to opioid administration and monitoring in primary care practices. A more structured drug testing strategy is needed to identify nonadherent patients. PMID:17372797

The Patient-Surgeon Relationship in the Cyber Era: Communication and Information

PubMed Central

Blake, J. Herman; Schwemmer, Mary Kay; Sade, Robert M.

2012-01-01

Synopsis From Laennec’s invention of the stethoscope in 1816 to the recently introduced Sapien transcatheter aortic valve replacement, the increasing complexity of health care technology has altered the relationship between patients and physicians, usually for the better. Telemedicine, the provision of medical services through electronic media, has dramatically changed how the patient and physician interact and how medical care is delivered. A consistent pattern of increased use of the Internet by patients and their families has been well documented. Patients clearly want more Internet interactions with clinicians in their quest for general information, prescription renewals, and such administrative matters as scheduling appointments. Despite privacy concerns, patients are generally satisfied that their communications and medical records are confidential and accurate. Physicians’ utilization of information technology has increased as the range of electronic devices and modes of communication has expanded. Many studies of physicians’ perceptions of electronic communication with patients have documented recognition of benefits as well as a consistent chorus of concerns about confidentiality, increased workload, inappropriate use, and medicolegal issues. PMID:23084616

Representation and Use of Temporal Information in ONCOCIN

PubMed Central

Kahn, Michael G.; Ferguson, Jay C.; Shortliffe, Edward H.; Fagan, Lawrence M.

1985-01-01

The past medical history of a patient is a complex collection of events yet the understanding of these past events is critical for effective medical diagnostic and therapeutic decisions. Although computers can store vast quantities of patient data, diagnostic and therapeutic computer programs have had difficulty in accessing and analyzing collections of patient information that is clinically pertinent to a specific decision facing a particular patient at a given moment in his disease. Without some model of the patient's past, the computer cannot fully interpret the meaning of the available patient data. We present some of the difficulties that were encountered in ONCOCIN, a cancer chemotherapy planning program. This program must be able to reason about the patient's past treatment history in order to generate a therapy plan that is responsive to the problems he or she may have encountered in the past. A design is presented that supports a more intuitive approach to capture and analyze important temporal relationships in a patient's computer record. In order to represent the time course of a patient, we have implemented a structure called the temporal network and a temporal syntax for data storage and retrieval. Using this system, ONCOCIN is able to quickly obtain data that is patient-specific and context-sensitive. Adding the temporal network to the ONCOCIN system has markedly improved the program's handling of complex temporal issues.

A web-based rapid prototyping and clinical conversational system that complements electronic patient record system.

PubMed

Kim, J H; Ferziger, R; Kawaloff, H B; Sands, D Z; Safran, C; Slack, W V

2001-01-01

Even the most extensive hospital information system cannot support all the complex and ever-changing demands associated with a clinical database, such as providing department or personal data forms, and rating scales. Well-designed clinical dialogue programs may facilitate direct interaction of patients with their medical records. Incorporation of extensive and loosely structured clinical data into an existing medical record system is an essential step towards a comprehensive clinical information system, and can best be achieved when the practitioner and the patient directly enter the contents. We have developed a rapid prototyping and clinical conversational system that complements the electronic medical record system, with its generic data structure and standard communication interfaces based on Web technology. We believe our approach can enhance collaboration between consumer-oriented and provider-oriented information systems.

Cues and concerns by patients in medical consultations: a literature review.

PubMed

Zimmermann, Christa; Del Piccolo, Lidia; Finset, Arnstein

2007-05-01

The aim of the current article is to review the peer-reviewed research literature on cues and concerns published between 1975 and 2006. To be included, articles had to report observational studies based on patient-physician consultations and report findings on patient expressions of cues and/or concerns. Quantitative and qualitative studies from different medical settings were considered. Fifty-eight original articles based on the analysis of audio- or videotaped medical consultations were tracked down. Definition of cues and concerns and methodological approaches differed widely. Physicians missed most cues and concerns and adopted behaviors that discouraged disclosure. Communication training improved the detection of cues and concerns. Future research progress would require different methodological approaches more appropriate for studying verbal interactions and the complexity of the various levels that influence interactions. (c) 2007 APA, all rights reserved

[Diagnosis and treatment of depression in the advanced stage of cancer].

PubMed

Ronson, A

2002-10-01

The diagnosis of depression in patients with advanced cancer is a particularly complex task. The lack of diagnostic tools specifically developed for this patient population, the difficulty of interpreting neurovegetative symptoms of depression--which can result from the neoplastic disease--and the "normal and understandable" nature of many symptoms or signs of psychological distress are among the main obstacles to a clear-cut diagnosis of depression. Things go even more complex when it comes about to discuss whether one should treat patients displaying psychological distress that does not meet established criteria for the diagnosis of a depressive illness. When the indication to treat is finally acknowledged, the choice of the optimal antidepressant will depend upon a series of parameters including survival expectancy, tolerance profile and drug interactions. Though we currently lack prospective data about the efficacy and safety of antidepressants in depressed patients with advanced cancer, extrapolation of data available from other patient populations with severe medical conditions and clinical experience allow to draw guidelines aimed at helping healthcare professionals faced with those problems to improve the quality of life of their patients. These elements are presented and discussed in this paper in the light of the recent developments resulting from the growing interest of the medical community to the care to patients with terminal illness.

Key concepts relevant to quality of complex and shared decision-making in health care: a literature review.

PubMed

Dy, Sydney M; Purnell, Tanjala S

2012-02-01

High-quality provider-patient decision-making is key to quality care for complex conditions. We performed an analysis of key elements relevant to quality and complex, shared medical decision-making. Based on a search of electronic databases, including Medline and the Cochrane Library, as well as relevant articles' reference lists, reviews of tools, and annotated bibliographies, we developed a list of key concepts and applied them to a decision-making example. Key concepts identified included provider competence, trustworthiness, and cultural competence; communication with patients and families; information quality; patient/surrogate competence; and roles and involvement. We applied this concept list to a case example, shared decision-making for live donor kidney transplantation, and identified the likely most important concepts as provider and cultural competence, information quality, and communication with patients and families. This concept list may be useful for conceptualizing the quality of complex shared decision-making and in guiding research in this area. Copyright © 2011 Elsevier Ltd. All rights reserved.

A new leadership role for pharmacists: a prescription for change.

PubMed

Burgess, L Hayley; Cohen, Michael R; Denham, Charles R

2010-03-01

Pharmacists can play an important role as leaders to reduce patient safety risks, optimize the safe function of medication management systems, and align pharmacy services with national initiatives that measure and reward quality performance. The objective of this article is to determine the actions that pharmacists can take to create a visible and sustainable safe medication management structure and system in the health care environment. An evidence-based literature search was performed to determine what actions successful pharmacist leaders have taken to improve patient safety. There is a growing number of quality and patient safety standards, as well as measures that focus specifically on medication use and education. Health care organizations must be made aware of the valuable resources that pharmacists provide and of the complexity of medication management. There are steps that pharmacist leaders can take to achieve these goals. The 10 steps that pharmacist leaders can take to create a visible and sustainable safe medication management structure and system are the following: 1. Identify and mitigate medication management risks and hazards to reduce preventable patient harm. 2. Establish pharmacy leadership structures and systems to ensure organizational awareness of medication safety gaps. 3. Support an organizational culture of safe medication use. 4. Ensure evidence-based medication regimens for all patients. 5. Have daily check-in calls/meetings, with the primary focus on significant safety or quality issues. 6. Establish a medication safety committee. 7. Perform medication safety walk-rounds to evaluate medication processes, and request front-line staff ’s input about medication safe practices. 8. Ensure that pharmacy staff engage in teamwork, skill building, and communication training. 9. Engage in readiness planning for implementation of health information technology (HIT). 10. Include medication history-taking and reviews upon entry into the organization; medication counseling and training during the discharge process; and follow-up after the transition to home.

Managing Complexity: Exploring Decision Making on Medication by Young Adults with ADHD.

PubMed

Druedahl, Louise C; Kälvemark Sporrong, Sofia

2018-04-19

Attention-deficit hyperactivity disorder (ADHD) causes difficulties with hyperactivity, impulsivity and inattention. Treatment of ADHD includes both medication and non-pharmacological options. Knowledge of treatment preferences by young adults with ADHD is sparse. The objective of this study was to explore the beliefs and experiences of young adults with ADHD related to their medication treatment decisions. Data were collected in Denmark in 2016 through a focus group and individual in-depth interviews. Conventional content analysis was used. Ten young adults with ADHD (22-to 29-year-old) participated. Three major themes were identified: (1) the patient’s right to choose concerning ADHD medicine; (2) the patient’s decision of whether or not to treat ADHD with medication; and (3) factors affecting the patient’s decision on whether to take ADHD medication or not. The latter theme contained 15 factors, which were distributed across three levels: individual, between-individuals, and societal. The dominant factors were increasing quality of life and improving oneself e.g., improving social skills. For counselling at the pharmacy and by prescribers, it is important to be aware of the different factors that affect young adult patients’ decisions on whether to take ADHD medication or not. This knowledge will aid to understand reasons for non-adherence and to determine appropriate treatment for the individual patient.

What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system.

PubMed

Hanefeld, Johanna; Smith, Richard; Horsfall, Daniel; Lunt, Neil

2014-01-01

Medical tourism is a growing phenomenon. This review of the literature maps current knowledge and discusses findings with reference to the UK National Health Service (NHS). Databases were systematically searched between September 2011 and March 2012 and 100 papers were selected for review. The literature shows specific types of tourism depending on treatment, eg, dentistry, cosmetic, or fertility. Patient motivation is complex and while further research is needed, factors beyond cost, including availability and distance, are clearly important. The provision of medical tourism varies. Volume of patient travel, economic cost and benefit were established for 13 countries. It highlights contributions not only to recipient countries' economies but also to a possible growth in health systems' inequities. Evidence suggests that UK patients travel abroad to receive treatment, complications arise and are treated by the NHS, indicating costs from medical travel for originating health systems. It demonstrates the importance of quality standards and holds lessons as the UK and other EU countries implement the EU Directive on cross-border care. Lifting the private-patient-cap for NHS hospitals increases potential for growth in inbound medical tourism; yet no research exists on this. Research is required on volume, cost, patient motivation, industry, and on long-term health outcomes in medical tourists. © 2014 International Society of Travel Medicine.

Overlay removable denture for treatment of worn teeth.

PubMed

Beyth, Nurit; Tamari, Israel; Buller Sharon, Anat

2014-01-01

Rehabilitation of partially edentulous patients with excessively worn dentitions can be challenging. Factors including medical history as well as the cost of the treatment and patient wishes for simpler approaches must be considered. This manuscript describes the use of an overlay partial denture to treat patients with excessive wear of the maxillary teeth. We describe a technique to restore severely worn teeth using heat-cured acrylic as part of a partial or full denture. Minimal preparations of the teeth are required, and the restoration provides protection from further wear, and stabilizes the occlusion. This solution was functionally and esthetically suitable to the patients. The technique can be used in medically complex patients where extractions are contraindicated, such as post radiation therapy or bisphosphonate treatment. © 2014 Special Care Dentistry Association and Wiley Periodicals, Inc.

[Centers for bariatric medicine : why and how ?

PubMed

Mégevand, Jean-Marie; Vignaux, Laurence; Maghdessian, Raffi; Pralong, François

2018-03-21

Obesity is a chronic, complex and relapsing disease. Because of this complexity, work up and follow up of affected patients implicate different specialists, working in synergy to diagnose and treat obesity and its complications. This follow up is specialized, and should be available in integrated centers of bariatric medicine offering all modalities of treatments with proven efficacy, whether medical, surgical or psychotherapeutical.

Estimated Cost-Effectiveness, Cost Benefit, and Risk Reduction Associated with an Endocrinologist-Pharmacist Diabetes Intense Medical Management "Tune-Up" Clinic.

PubMed

Hirsch, Jan D; Bounthavong, Mark; Arjmand, Anisa; Ha, David R; Cadiz, Christine L; Zimmerman, Andrew; Ourth, Heather; Morreale, Anthony P; Edelman, Steven V; Morello, Candis M

2017-03-01

In 2012 U.S. diabetes costs were estimated to be $245 billion, with $176 billion related to direct diabetes treatment and associated complications. Although a few studies have reported positive glycemic and economic benefits for diabetes patients treated under primary care physician (PCP)-pharmacist collaborative practice models, no studies have evaluated the cost-effectiveness of an endocrinologist-pharmacist collaborative practice model treating complex diabetes patients versus usual PCP care for similar patients. To estimate the cost-effectiveness and cost benefit of a collaborative endocrinologist-pharmacist Diabetes Intense Medical Management (DIMM) "Tune-Up" clinic for complex diabetes patients versus usual PCP care from 3 perspectives (clinic, health system, payer) and time frames. Data from a retrospective cohort study of adult patients with type 2 diabetes mellitus (T2DM) and glycosylated hemoglobin A1c (A1c) ≥ 8% who were referred to the DIMM clinic at the Veterans Affairs San Diego Health System were used for cost analyses against a comparator group of PCP patients meeting the same criteria. The DIMM clinic took more time with patients, compared with usual PCP visits. It provided personalized care in three 60-minute visits over 6 months, combining medication therapy management with patient-specific diabetes education, to achieve A1c treatment goals before discharge back to the PCP. Data for DIMM versus PCP patients were used to evaluate cost-effectiveness and cost benefit. Analyses included incremental cost-effectiveness ratios (ICERs) at 6 months, 3-year estimated total medical costs avoided and return on investment (ROI), absolute risk reduction of complications, resultant medical costs, and quality-adjusted life-years (QALYs) over 10 years. Base case ICER results indicated that from the clinic perspective, the DIMM clinic costs $21 per additional percentage point of A1c improvement and $115-$164 per additional patient at target A1c goal level compared with the PCP group. From the health system perspective, medical cost avoidance due to improved A1c was $8,793 per DIMM patient versus $3,506 per PCP patient (P = 0.009), resulting in an ROI of $9.01 per dollar spent. From the payer perspective, DIMM patients had estimated lower total medical costs, a greater number of QALYs gained, and appreciable risk reductions for diabetes-related complications over 2-, 5- and 10-year time frames, indicating that the DIMM clinic was dominant. Sensitivity analyses indicated results were robust, and overall conclusions did not change appreciably when key parameters (including DIMM clinic effectiveness and cost) were varied within plausible ranges. The DIMM clinic endocrinologist-pharmacist collaborative practice model, in which the pharmacist spent more time providing personalized care, improved glycemic control at a minimal cost per additional A1c benefit gained and produced greater cost avoidance, appreciable ROI, reduction in long-term complication risk, and lower cost for a greater gain in QALYs. Overall, the DIMM clinic represents an advanced pharmacy practice model with proven clinical and economic benefits from multiple perspectives for patients with T2DM and high medication and comorbidity complexity. No outside funding supported this study. The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Preliminary versions of the study data were presented in abstract form at the American Pharmacists Association Annual Meeting & Exposition; March 27, 2015; San Diego, California, and the Academy of Managed Care Pharmacy Annual Meeting; April 21, 2016; San Francisco, California. Study concept and design were contributed by Hirsch, Bounthavong, and Edelman, along with Morello and Morreale. Arjmand, Ourth, Ha, Cadiz, and Zimmerman collected the data. Data interpretation was performed by Ha, Morreale, and Morello, along with Cadiz, Ourth, and Hirsch. The manuscript was written primarily by Hirsch and Zimmerman, along with Arjamand, Ourth, and Morello, and was revised by Hirsch and Cadiz, along with Bounthavong, Ha, Morreale, and Morello.

Medication errors in the emergency department: a systems approach to minimizing risk.

PubMed

Peth, Howard A

2003-02-01

Adverse drug events caused by medication errors represent a common cause of patient injury in the practice of medicine. Many medication errors are preventable and hence particularly tragic when they occur, often with serious consequences. The enormous increase in the number of available drugs on the market makes it all but impossible for physicians, nurses, and pharmacists to possess the knowledge base necessary for fail-safe medication practice. Indeed, the greatest single systemic factor associated with medication errors is a deficiency in the knowledge requisite to the safe use of drugs. It is vital that physicians, nurses, and pharmacists have at their immediate disposal up-to-date drug references. Patients presenting for care in EDs are usually unfamiliar to their EPs and nurses, and the unique patient factors affecting medication response and toxicity are obscured. An appropriate history, physical examination, and diagnostic workup will assist EPs, nurses, and pharmacists in selecting the safest and most optimum therapeutic regimen for each patient. EDs deliver care "24/7" and are open when valuable information resources, such as hospital pharmacists and previously treating physicians, may not be available for consultation. A systems approach to the complex problem of medication errors will help emergency clinicians eliminate preventable adverse drug events and achieve a goal of a zero-defects system, in which medication errors are a thing of the past. New developments in information technology and the advent of electronic medical records with computerized physician order entry, ward-based clinical pharmacists, and standardized bar codes promise substantial reductions in the incidence of medication errors and adverse drug events. ED patients expect and deserve nothing less than the safest possible emergency medicine service.

Implementation of Electronic Checklists in an Oncology Medical Record: Initial Clinical Experience

PubMed Central

Albuquerque, Kevin V.; Miller, Alexis A.; Roeske, John C.

2011-01-01

Purpose: The quality of any medical treatment depends on the accurate processing of multiple complex components of information, with proper delivery to the patient. This is true for radiation oncology, in which treatment delivery is as complex as a surgical procedure but more dependent on hardware and software technology. Uncorrected errors, even if small or infrequent, can result in catastrophic consequences for the patient. We developed electronic checklists (ECLs) within the oncology electronic medical record (EMR) and evaluated their use and report on our initial clinical experience. Methods: Using the Mosaiq EMR, we developed checklists within the clinical assessment section. These checklists are based on the process flow of information from one group to another within the clinic and enable the processing, confirmation, and documentation of relevant patient information before the delivery of radiation therapy. The clinical use of the ECL was documented by means of a customized report. Results: Use of ECL has reduced the number of times that physicians were called to the treatment unit. In particular, the ECL has ensured that therapists have a better understanding of the treatment plan before the initiation of treatment. An evaluation of ECL compliance showed that, with additional staff training, > 94% of the records were completed. Conclusion: The ECL can be used to ensure standardization of procedures and documentation that the pretreatment checks have been performed before patient treatment. We believe that the implementation of ECLs will improve patient safety and reduce the likelihood of treatment errors. PMID:22043184

WE-D-303-01: Development and Application of Digital Human Phantoms

DOE Office of Scientific and Technical Information (OSTI.GOV)

Segars, P.

2015-06-15

Modern medical physics deals with complex problems such as 4D radiation therapy and imaging quality optimization. Such problems involve a large number of radiological parameters, and anatomical and physiological breathing patterns. A major challenge is how to develop, test, evaluate and compare various new imaging and treatment techniques, which often involves testing over a large range of radiological parameters as well as varying patient anatomies and motions. It would be extremely challenging, if not impossible, both ethically and practically, to test every combination of parameters and every task on every type of patient under clinical conditions. Computer-based simulation using computationalmore » phantoms offers a practical technique with which to evaluate, optimize, and compare imaging technologies and methods. Within simulation, the computerized phantom provides a virtual model of the patient’s anatomy and physiology. Imaging data can be generated from it as if it was a live patient using accurate models of the physics of the imaging and treatment process. With sophisticated simulation algorithms, it is possible to perform virtual experiments entirely on the computer. By serving as virtual patients, computational phantoms hold great promise in solving some of the most complex problems in modern medical physics. In this proposed symposium, we will present the history and recent developments of computational phantom models, share experiences in their application to advanced imaging and radiation applications, and discuss their promises and limitations. Learning Objectives: Understand the need and requirements of computational phantoms in medical physics research Discuss the developments and applications of computational phantoms Know the promises and limitations of computational phantoms in solving complex problems.« less

Critical elements and lessons learnt from the implementation of an RFID-enabled healthcare management system in a medical organization.

PubMed

Ting, S L; Kwok, S K; Tsang, Albert H C; Lee, W B

2011-08-01

Healthcare services are complex and life-critical. One mistake in any procedure may lead to irremediable consequences; numerous researchers, thus, introduce information and communication technology to improve quality of services and enhance patient safety by reducing the medical errors. Radio frequency identification (RFID) is considered as one of the emerging tool assist in meeting the challenges of the present situation. In recent years, RFID has been applied in medical organizations for the purpose of managing and tracking medical equipment, monitoring and identifying patients, ensuring that the right medication is given to the right patient, and preventing the use of counterfeit medicine. However, most of the existing literature focuses on demonstrating how RFID can benefit the healthcare industry, whereas little attention has been given to the management issues involved in constructing an RFID project in medical organizations. In this paper, an exploratory case study is conducted in a medical organization to illustrate the development framework and critical issues that should be taken into consideration in the preparation, implementation and maintenance stage of constructing such a project. All the experiences and results discussed in this paper offer valuable and useful insights to steer those who would like to start their journey using RFID in medical organizations.

Measuring Safety: A New Perspective on Outcomes of a Long-Term Intensive Case Management Program

DTIC Science & Technology

2005-05-01

treatment; complex treatment regimen, like electroconvulsive therapy (ECT), or new technologies; discharge against medical advice from inpatient...treatment; refractory to medication interventions; and need for therapy or psychiatric nursing in the home. While patients meeting the high acuity case...outpatient settings; individual, group, and family therapy ; and chemical dependency services. Exceptions to benefit limits were granted as needed, per

Primary care providers' experiences caring for complex patients in primary care: a qualitative study.

PubMed

Loeb, Danielle F; Bayliss, Elizabeth A; Candrian, Carey; deGruy, Frank V; Binswanger, Ingrid A

2016-03-22

Complex patients are increasingly common in primary care and often have poor clinical outcomes. Healthcare system barriers to effective care for complex patients have been previously described, but less is known about the potential impact and meaning of caring for complex patients on a daily basis for primary care providers (PCPs). Our objective was to describe PCPs' experiences providing care for complex patients, including their experiences of health system barriers and facilitators and their strategies to enhance provision of effective care. Using a general inductive approach, our qualitative research study was guided by an interpretive epistemology, or way of knowing. Our method for understanding included semi-structured in-depth interviews with internal medicine PCPs from two university-based and three community health clinics. We developed an interview guide, which included questions on PCPs' experiences, perceived system barriers and facilitators, and strategies to improve their ability to effectively treat complex patients. To focus interviews on real cases, providers were asked to bring de-identified clinical notes from patients they considered complex to the interview. Interview transcripts were coded and analyzed to develop categories from the raw data, which were then conceptualized into broad themes after team-based discussion. PCPs (N = 15) described complex patients with multidimensional needs, such as socio-economic, medical, and mental health. A vision of optimal care emerged from the data, which included coordinating care, preventing hospitalizations, and developing patient trust. PCPs relied on professional values and individual care strategies to overcome local and system barriers. Team based approaches were endorsed to improve the management of complex patients. Given the barriers to effective care described by PCPs, individual PCP efforts alone are unlikely to meet the needs of complex patients. To fulfill PCP's expressed concepts of optimal care, implementation of effective systemic approaches should be considered.

Nursing on the medical ward.

PubMed

Parker, Judith M

2004-12-01

This paper considers some issues confronting contemporary medical nursing and draws upon psychoanalytic theories to investigate some seemingly straightforward and taken-for-granted areas of medical nursing work. I am arguing that the everyday work of medical nurses in caring for patients is concerned with bringing order to and placing boundaries around inherently unsettled and destabilized circumstances. I am also arguing that how nurses manage and organize their work in this regard stems from traditional practices that tend to be taken for granted and not explicitly thought about. It is therefore difficult for nurses to consider changing these practices that often have negative consequences for the nurses. I want to examine the impact upon nurses of the consequences of three taken-for-granted nursing practices: (i) the tendency of nurses to confine their reactions to what is going on so as to present a caring self; (ii) the tendency of nurses in their everyday talk to patients to confine, limit and minimize meaning; and (iii) the tensions and ambiguities that emerge for nurses in the policing function they perform in confining patients to the bed or the ward. Negative consequences on nurses of these practices potentially include stress and confusion regarding their ability to care for patients; an undervaluing of nursing skills; and a deterioration in the nurse-patient relationship. Clinical supervision for medical nurses is proposed as a means of facilitating greater understanding of the nature of nurses' relationships with patients and the complex dimensions of their medical nursing role.

Does applying technology throughout the medication use process improve patient safety with antineoplastics?

PubMed

Bubalo, Joseph; Warden, Bruce A; Wiegel, Joshua J; Nishida, Tess; Handel, Evelyn; Svoboda, Leanne M; Nguyen, Lam; Edillo, P Neil

2014-12-01

Medical errors, in particular medication errors, continue to be a troublesome factor in the delivery of safe and effective patient care. Antineoplastic agents represent a group of medications highly susceptible to medication errors due to their complex regimens and narrow therapeutic indices. As the majority of these medication errors are frequently associated with breakdowns in poorly defined systems, developing technologies and evolving workflows seem to be a logical approach to provide added safeguards against medication errors. This article will review both the pros and cons of today's technologies and their ability to simplify the medication use process, reduce medication errors, improve documentation, improve healthcare costs and increase provider efficiency as relates to the use of antineoplastic therapy throughout the medication use process. Several technologies, mainly computerized provider order entry (CPOE), barcode medication administration (BCMA), smart pumps, electronic medication administration record (eMAR), and telepharmacy, have been well described and proven to reduce medication errors, improve adherence to quality metrics, and/or improve healthcare costs in a broad scope of patients. The utilization of these technologies during antineoplastic therapy is weak at best and lacking for most. Specific to the antineoplastic medication use system, the only technology with data to adequately support a claim of reduced medication errors is CPOE. In addition to the benefits these technologies can provide, it is also important to recognize their potential to induce new types of errors and inefficiencies which can negatively impact patient care. The utilization of technology reduces but does not eliminate the potential for error. The evidence base to support technology in preventing medication errors is limited in general but even more deficient in the realm of antineoplastic therapy. Though CPOE has the best evidence to support its use in the antineoplastic population, benefit from many other technologies may have to be inferred based on data from other patient populations. As health systems begin to widely adopt and implement new technologies it is important to critically assess their effectiveness in improving patient safety. © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Systems Medicine 2.0: Potential Benefits of Combining Electronic Health Care Records With Systems Science Models

PubMed Central

Gibson, Alexander R; Scott, Gregory; Harrison, Oliver; Dominiczak, Anna; Hanlon, Phil

2015-01-01

Background The global burden of disease is increasingly dominated by non-communicable diseases.These diseases are less amenable to curative and preventative interventions than communicable disease. This presents a challenge to medical practice and medical research, both of which are experiencing diminishing returns from increasing investment. Objective Our aim was to (1) review how medical knowledge is generated, and its limitations, (2) assess the potential for emerging technologies and ideas to improve medical research, and (3) suggest solutions and recommendations to increase medical research efficiency on non-communicable diseases. Methods We undertook an unsystematic review of peer-reviewed literature and technology websites. Results Our review generated the following conclusions and recommendations. (1) Medical knowledge continues to be generated in a reductionist paradigm. This oversimplifies our models of disease, rendering them ineffective to sufficiently understand the complex nature of non-communicable diseases. (2) Some of these failings may be overcome by adopting a “Systems Medicine” paradigm, where the human body is modeled as a complex adaptive system. That is, a system with multiple components and levels interacting in complex ways, wherein disease emerges from slow changes to the system set-up. Pursuing systems medicine research will require larger datasets. (3) Increased data sharing between researchers, patients, and clinicians could provide this unmet need for data. The recent emergence of electronic health care records (EHR) could potentially facilitate this in real-time and at a global level. (4) Efforts should continue to aggregate anonymous EHR data into large interoperable data silos and release this to researchers. However, international collaboration, data linkage, and obtaining additional information from patients will remain challenging. (5) Efforts should also continue towards “Medicine 2.0”. Patients should be given access to their personal EHR data. Subsequently, online communities can give researchers the opportunity to ask patients for direct access to the patient’s EHR data and request additional study-specific information. However, selection bias towards patients who use Web 2.0 technology may be difficult to overcome. Conclusions Systems medicine, when combined with large-scale data sharing, has the potential to raise our understanding of non-communicable diseases, foster personalized medicine, and make substantial progress towards halting, curing, and preventing non-communicable diseases. Large-scale data amalgamation remains a core challenge and needs to be supported. A synthesis of “Medicine 2.0” and “Systems Science” concepts into “Systems Medicine 2.0” could take decades to materialize but holds much promise. PMID:25831125

Timing of Initiation of Maintenance Dialysis

PubMed Central

Wong, Susan P. Y.; Vig, Elizabeth K.; Taylor, Janelle S.; Burrows, Nilka R.; Liu, Chuan-Fen; Williams, Desmond E.; Hebert, Paul L.; O’Hare, Ann M.

2016-01-01

IMPORTANCE There is often considerable uncertainty about the optimal time to initiate maintenance dialysis in individual patients and little medical evidence to guide this decision. OBJECTIVE To gain a better understanding of the factors influencing the timing of initiation of dialysis in clinical practice. DESIGN, SETTING, AND PARTICIPANTS A qualitative analysis was conducted using the electronic medical records from the Department of Veterans Affairs (VA) of a national random sample of 1691 patients for whom the decision to initiate maintenance dialysis occurred in the VA between January 1, 2000, and December 31, 2009. Data analysis took place from June 1 to November 30, 2014. MAIN OUTCOMES AND MEASURES Central themes related to the timing of initiation of dialysis as documented in patients’ electronic medical records. RESULTS Of the 1691 patients, 1264 (74.7%) initiated dialysis as inpatients and 1228 (72.6%) initiated dialysis with a hemodialysis catheter. Cohort members met with a nephrologist during an outpatient clinic visit a median of 3 times (interquartile range, 0–6) in the year prior to initiation of dialysis. The mean (SD) estimated glomerular filtration rate at the time of initiation for cohort members was 10.4 (5.7) mL/min/1.73m2. The timing of initiation of dialysis reflected the complex interplay of at least 3 interrelated and dynamic processes. The first was physician practices, which ranged from practices intended to prepare patients for dialysis to those intended to forestall the need for dialysis by managing the signs and symptoms of uremia with medical interventions. The second process was sources of momentum. Initiation of dialysis was often precipitated by clinical events involving acute illness or medical procedures. In these settings, the imperative to treat often seemed to override patient choice. The third process was patient-physician dynamics. Interactions between patients and physicians were sometimes adversarial, and physician recommendations to initiate dialysis sometimes seemed to conflict with patient priorities. CONCLUSIONS AND RELEVANCE The initiation of maintenance dialysis reflects the care practices of individual physicians, sources of momentum for initiation of dialysis, interactions between patients and physicians, and the complex interplay of these dynamic processes over time. Our findings suggest opportunities to improve communication between patients and physicians and to better align these processes with patients’ values, goals, and preferences. PMID:26809745

CE: Nursing's Evolving Role in Patient Safety.

PubMed

Kowalski, Sonya L; Anthony, Maureen

2017-02-01

: Background: In its 1999 report To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM) suggested that between 44,000 and 98,000 Americans die annually as a result of medical errors. The report urged health care institutions to break the silence surrounding such errors and to implement changes that would promote a culture of safety. Our aim in conducting this content analysis of AJN articles was to explore the nurse's historical and contemporary role in promoting patient safety. We chose to focus on AJN because, as the oldest continuously published nursing journal, it provided a unique opportunity for us to view trends in nursing practice over more than 100 years. We reviewed all AJN tables of contents from 1900 through 2015, identifying for inclusion articles with titles that suggested a focus on nursing care, patient safety, or clinical content. We then read and analyzed each of the final 1,086 articles over a period of nine months. Our content analysis indicates that the early articles (from 1900 through 1920) focused on such safety measures as asepsis and the newly understood germ theory. In the 1930s, articles proposed methods for preventing medication errors and encouraged the development of written procedures to standardize care. During World War II, nurse authors identified improved patient survival rates with the use of "shock wards" and recovery rooms. The 1950s saw the emergence of progressive patient care initiatives, through which patients were assigned to various levels of care (intensive, intermediate, self, long-term, or home care) based on patient acuity. The 1960s brought increasingly complex equipment and medication regimens, which created safety problems. Hospital-acquired infections were recognized. Unit-dose medication was instituted in the 1970s. In the next two decades, medication and nursing-procedure safety were emphasized. From 2000 to 2015, articles looked beyond human performance as causes of health care errors to systemic factors, such as poor communication, patient-nurse ratios, provider skill mix, disruptive or inappropriate provider behavior, shift work, and long working hours. Emphasis on patient safety increased as patient care became more complex. As nurses developed a professional identity, they often put a spotlight on safety concerns and solutions. The IOM report, which encouraged research focused on systemic solutions to errors, was instrumental in furthering the very culture of safety that the nursing profession had championed.

Empirical analysis of domestic medical travel for elective cardiovascular procedures.

PubMed

Langley, Jacob D; Johnson, Tricia J; Hohmann, Samuel F; Meurer, Steve J; Garman, Andy N

2013-10-01

To investigate whether domestic medical travel (DMT; traveling outside of one's home region but within the United States for medical care) and surgeon volume affect clinical outcomes and costs for patients undergoing elective cardiovascular procedures. Retrospective, cross-sectional analysis of patient discharge data from US academic medical centers. Patients were classified as medical travelers if they received elective, nonemergent care more than 250 miles from home. High-volume surgeons (HVSs) were those above the 75th percentile compared with other study surgeons in the annual number of cardiovascular surgeries performed. Multivariable regression models were fit to test the relationships among complications, mortality, length of stay (LOS), cost, DMT status, and surgeon volume, controlling for sociodemographic and clinical factors. Patients who traveled to HVSs were more likely to be male, white, have lower severity of illness, and have health insurance through an indemnity plan or preferred provider organization with coverage outside of the patient's home region. Patients who traveled to HVSs had shorter LOS and fewer complications than those who received care from local, low-volume surgeons. There was no significant difference in mortality between travelers and nontravelers. Patients who travelled to HVSs for elective cardiovascular procedures had outcomes similar to or better than those of patients who received care locally from low-volume surgeons. We found no increase in complications or LOS, despite potentially complex logistical arrangements required by travelers. More work is needed to evaluate the potential of DMT to improve the value of care provided for selected procedures.

An analysis of clinical outcomes and costs of a long term acute care hospital.

PubMed

Votto, John J; Scalise, Paul J; Barton, Randall W; Vogel, Cristine A

2011-01-01

Compare clinical outcomes and costs in a study group of long-term acute care hospital (LTCH) patients with a control group of LTCH-eligible patients in an acute care hospital. LTCHs were created to provide post-acute care services not available at other post-acute settings. This is based on the premise that these patients would otherwise have stayed at acute care hospitals as high-cost outliers. The LTCH hospital is intended to deliver care to patients more efficiently, however, there are little documented clinical and financial data regarding the comparative clinical outcomes and costs for patients. Retrospective medical and billing record review of patients from the following groups: (1) LTCH study comprising patients admitted directly from an acute care hospital to the study LTCH and discharged from the LTCH from September 2004 through August 2006; (2) a control group of LTCH-eligible, medically complex patients treated and discharged from an acute care hospital in FY 2002. The control group was selected from approximately 500 patients who had at least one of the ten most common principle diagnosis DRGs of the study LTCH with >30-day length of stay at the referring hospital and met NALTH admitting guidelines. Discharge disposition is an important outcome measure of the quality of care of medically complex patients. The in-hospital mortality rate trended lower and home discharge was 3 times higher for the LTCH study group than for the control group. As a possible result, SNF discharge of LTCH patients was approximately half that of the control group. Both mean patient cost per day and mean total cost per patient were significantly higher in the control group than in the LTCH study group. The patients in the LTCH study group had both better clinical outcomes and lower cost of care than the control group.

Dental Management of a Pediatric Patient with Moyamoya Syndrome: A Rare Clinical Entity.

PubMed

Ko, Brittany L; Unkel, John H

2018-01-01

Moyamoya disease (MMD) is a rare cerebrovascular disorder involving progressive constriction of the internal carotid artery and its branches. The disease has a particularly aggressive course in very young patients, and early surgical intervention is often necessary to prevent permanent neurological damage. MMD patients have an increased risk of stroke development, which may be provoked by pain or anxiety. Currently, no reports of pediatric patients with MMD exist in the dental literature. The purpose of this paper was to discuss the dental management of a two-year-old with moyamoya disease who presented with early childhood caries and dental fear, offering recommendations for dental providers with emphasis on stroke prevention, collaboration with the medical team, anesthesia considerations for patients with increased stroke risk, and the challenges to maintain the oral health of a patient undergoing complex medical treatment.

Deprescribing for frail older people - Learning from the case of Mrs. Hansen.

PubMed

Granas, Anne Gerd; Stendal Bakken, Marit; Ruths, Sabine; Taxis, Katja

2017-07-13

Drug treatment is often an essential part in treatment and prevention of diseases in older people, but there is much concern about inappropriate medication use. This paper aims to describe the complexity of medication safety issues and clinical judgments when optimizing prescribing in older individuals. It uses the case of Mrs. Hansen, an aged nursing home resident, to illustrate the facilitators and barriers of this process. With decreasing life expectancy, medication use should shift from cure to care, focusing on symptomatic treatment to increase the patient's well-being. In Mrs. Hansen's case, the number of (potentially) dangerous medications were reduced, and non-pharmacological alternatives were considered. There were some medicines added, as underprescribing can also be a problem in older people. Deprescribing long-standing treatment can be interpreted by the patient and family as "giving up hope". More clinical evidence and practical communication tools are needed to guide deprescribing decisions, taking medical and patient-centered priorities into account. Studies evaluating such interventions should select outcome measures that are particularly relevant for frail old individuals. Copyright © 2017. Published by Elsevier Inc.

Pediatric and neonatal cardiovascular pharmacology.

PubMed

Miller-Hoover, Suzan R

2003-01-01

Advances in cardiology, surgical techniques, postoperative care, and medications have improved the chances of long-term survival of the neonatal and pediatric patient with complex congenital cardiac anomalies. Rather than undergoing palliative repair, these children are now frequently taken to the operating room for complete repair. As complete repair becomes the norm, collaborative management and a thorough understanding of the pre and postoperative medications used become essential to the care of these patients. The nurse's ability to understand preop, postop, and management medications is enhanced by an understanding of the principles of cardiac anatomy and physiology, as well as developmental changes in cardiac function. All of these are reviewed. In addition, since the safe and effective administration of these drugs depends on the pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU) nurse's thorough knowledge of these medications and their effects on the cardiovascular system, a brief review of these medications is presented. While new technology and techniques are improving survival rates for children with congenital heart anomalies, it is the postoperative care that these children receive that enhances the patient's survival even more.

Motivation in medical education and patient communication. The EGPRN meeting in Zurich, Switzerland, October 2010.

PubMed

Rethans, Jan-Joost; Donner-Banzhoff, Norbert

2011-06-01

The European General Practice Research Network held an international research meeting on 'Motivation in medical education and patient communication' in Zürich, Switzerland, in October 2010. The two authors were keynote speakers, who introduced the theme from different angles and summarized and reflected on individual papers presented at the conference. The theme of the conference underlined the importance of communication in general practice and of motivation in medical education in particular. There were a variety of papers each addressing in its own way the topic of this meeting. We conclude that it is still uncommon to use psychological theories on motivation in research on motivation and patient communication in general practice/family medicine. Motivation and readiness to change are essential concepts in experimental health services research. Research designs increasingly follow the Framework for the Evaluation of Complex Interventions in Health Care as suggested by the British Medical Research Council. However, there are also difficulties related to classical experimental designs that have to be critically discussed.

Chronic pain as a manifestation of potassium channel-complex autoimmunity

PubMed Central

Lennon, Vanda A.; Aston, Paula A.; McKeon, Andrew; Pittock, Sean J.

2012-01-01

Objective: Autoantibodies targeting voltage-gated potassium channel (VGKC) complexes cause a spectrum of neuronal hyperexcitability disorders. We investigated pain as a manifestation of VGKC-complex autoimmunity. Methods: We reviewed the prevalence and characteristics of pain in VGKC-complex-immunoglobulin G (IgG)–seropositive patients in 25 months of comprehensive service testing for neural autoantibodies, subtyped positive sera for LGI1-IgG and CASPR2-IgG specificities, and reviewed pain prevalence in autoimmune control patients. Results: VGKC-complex-IgG was identified in 1,992 patients of 54,853 tested (4%). Of 316 evaluated neurologically at Mayo Clinic, 159 (50%) had pain, in isolation (28%) or with accompanying neurologic manifestations (72%), and not attributable to alternative cause. Pain was subacute in onset, chronic in course, neuropathic, nociceptive, regional, or diffuse and sometimes attributed to fibromyalgia (6%) or psychogenic cause (13%). Most patients had normal peripheral nervous system function, measured by neuropathy impairment scores and nerve conduction. Evidence of neuronal hyperexcitability (hyperhidrosis, quantitative heat-pain hyperalgesia, or electromyographic excitability) was 25-fold more common in pain patients. Pain management required multiple medications in 70% (narcotics, 30%); 13 of 16 patients reported pain relief with immunotherapy. Pain was significantly associated with CASPR2-IgG-positivity (16% positive with pain, 7% without pain; p = 0.014) but not with LGI1-IgG. Less than 10% of 167 patients with neural autoantibodies other than VGKC-complex-IgG reported pain. Conclusions: Chronic idiopathic pain is a syndromic manifestation of VGKC-complex autoimmunity. Hyperexcitability of nociceptive pathways is implicated. CASPR2-IgG significantly associates with pain, but in most patients the antigenic VGKC-complex molecule remains to be determined. VGKC-complex autoimmunity represents an important new direction for pain research and therapy. PMID:22895588

Chronic pain as a manifestation of potassium channel-complex autoimmunity.

PubMed

Klein, Christopher J; Lennon, Vanda A; Aston, Paula A; McKeon, Andrew; Pittock, Sean J

2012-09-11

Autoantibodies targeting voltage-gated potassium channel (VGKC) complexes cause a spectrum of neuronal hyperexcitability disorders. We investigated pain as a manifestation of VGKC-complex autoimmunity. We reviewed the prevalence and characteristics of pain in VGKC-complex-immunoglobulin G (IgG)-seropositive patients in 25 months of comprehensive service testing for neural autoantibodies, subtyped positive sera for LGI1-IgG and CASPR2-IgG specificities, and reviewed pain prevalence in autoimmune control patients. VGKC-complex-IgG was identified in 1,992 patients of 54,853 tested (4%). Of 316 evaluated neurologically at Mayo Clinic, 159 (50%) had pain, in isolation (28%) or with accompanying neurologic manifestations (72%), and not attributable to alternative cause. Pain was subacute in onset, chronic in course, neuropathic, nociceptive, regional, or diffuse and sometimes attributed to fibromyalgia (6%) or psychogenic cause (13%). Most patients had normal peripheral nervous system function, measured by neuropathy impairment scores and nerve conduction. Evidence of neuronal hyperexcitability (hyperhidrosis, quantitative heat-pain hyperalgesia, or electromyographic excitability) was 25-fold more common in pain patients. Pain management required multiple medications in 70% (narcotics, 30%); 13 of 16 patients reported pain relief with immunotherapy. Pain was significantly associated with CASPR2-IgG-positivity (16% positive with pain, 7% without pain; p = 0.014) but not with LGI1-IgG. Less than 10% of 167 patients with neural autoantibodies other than VGKC-complex-IgG reported pain. Chronic idiopathic pain is a syndromic manifestation of VGKC-complex autoimmunity. Hyperexcitability of nociceptive pathways is implicated. CASPR2-IgG significantly associates with pain, but in most patients the antigenic VGKC-complex molecule remains to be determined. VGKC-complex autoimmunity represents an important new direction for pain research and therapy.

Spinal fusion for scoliosis in Rett syndrome with an emphasis on early postoperative complications.

PubMed

Gabos, Peter G; Inan, Muharrem; Thacker, Mihir; Borkhu, Buttugs

2012-01-15

Retrospective case-control study. To examine the postoperative complications of posterior spinal fusion in a population of patients with Rett syndrome (RS). Scoliosis is a common feature of RS, a progressive neurologic disorder affecting almost exclusively females. Despite this, there is little published information regarding the surgical treatment of scoliosis in this disorder. Sixteen consecutive female patients with RS treated by posterior spinal fusion and unit rod instrumentation for progressive scoliosis between 1995 and 2003 were evaluated. Only patients with a minimum of 2-year follow-up were included. Preoperative medical conditions and postoperative complications were recorded. As a control group, we randomly selected 32 spastic quadriplegic patients who underwent the identical procedure during the same time period, selected from our database and matched according to age, level of neurologic impairment, and medical complexity. There was a high rate of early medical complications in the RS patients, with 28 major and 37 minor complications. Only 1 patient did not have a major medical complication, and every patient had at least 1 minor gastrointestinal and/or respiratory complication. Major respiratory complications occurred in 10 patients (63%) and comprised 61% of all major complications. Major gastrointestinal complications occurred in 6 patients (37%) and comprised 21% of all major complications. Other major complications included disseminated intravascular coagulopathy (1 patient), subacute bacterial endocarditis (1 patient), sacral decubiti requiring surgical debridement (2 patients), and extensive bilateral heterotopic ossification of the hips (1 patient). There were no cases of instrumentation failure, pseudarthrosis, deep infection, or need for rod revision. Postoperative complication scores were similar to those in patients with spastic quadriplegic pattern cerebral palsy. Spinal fusion for scoliosis in RS can give a satisfactory technical result, but a high rate of early postoperative medical problems should be anticipated.

A systematic review of clinical pharmacist interventions in paediatric hospital patients.

PubMed

Drovandi, Aaron; Robertson, Kelvin; Tucker, Matthew; Robinson, Niechole; Perks, Stephen; Kairuz, Therése

2018-06-19

Clinical pharmacists provide beneficial services to adult patients, though their benefits for paediatric hospital patients are less defined. Five databases were searched using the MeSH terms 'clinical pharmacist', 'paediatric/paediatric', 'hospital', and 'intervention' for studies with paediatric patients conducted in hospital settings, and described pharmacist-initiated interventions, published between January 2000 and October 2017. The search strategy after full-text review identified 12 articles matching the eligibility criteria. Quality appraisal checklists from the Joanna Briggs Institute were used to appraise the eligible articles. Clinical pharmacist services had a positive impact on paediatric patient care. Medication errors intercepted by pharmacists included over- and under-dosing, missed doses, medication history gaps, allergies, and near-misses. Interventions to address these errors were positively received, and implemented by physicians, with an average acceptance rate of over 95%. Clinical pharmacist-initiated education resulted in improved medication understanding and adherence, improved patient satisfaction, and control of chronic medical conditions. This review found that clinical pharmacists in paediatric wards may reduce drug-related problems and improve patient outcomes. The benefits of pharmacist involvement appear greatest when directly involved in ward rounds, due to being able to more rapidly identify medication errors during the prescribing phase, and provide real-time advice and recommendations to prescribers. What is Known: • Complex paediatric conditions can require multiple pharmaceutical treatments, utilised in a safe manner to ensure good patient outcomes • The benefits of pharmacist interventions when using these treatments are well-documented in adult patients, though less so in paediatric patients What is New: • Pharmacists are adept at identifying and managing medication errors for paediatric patients, including incorrect doses, missed doses, and gaps in medication history • Interventions recommended by pharmacists are generally well-accepted by prescribing physicians, especially when recommendations can be made during the prescribing phase of treatment.

Lost in translation. Homer in English; the patient's story in medicine.

PubMed

Marshall, Robert J; Bleakley, Alan

2013-06-01

In a series of previous articles, we have considered how we might reconceptualise central themes in medicine and medical education through 'thinking with Homer'. This has involved using textual approaches, scenes and characters from the Iliad and Odyssey for rethinking what is a 'communication skill', and what do we mean by 'empathy' in medical practice; in what sense is medical practice formulaic, like a Homeric 'song'; and what is lyrical about medical practice. Our approach is not to historicise medicine and medical education, but to use thinking with Homer as a medium and metaphor for questioning the habitual and the taken-for-granted in contemporary practice. In this article, we tackle the complex theme of 'translation'. We use the lens of translation studies to examine the process of turning the patient's story into medical language. We address the questions: what makes a 'good' translation? What are the consequences of mistranslation and poor translation? And, while things are inevitably lost in translation, does this matter?

Outside the operating room: How a robotics program changed resource utilization on the inpatient Ward.

PubMed

Leung, Annie; Abitbol, Jeremie; Ramana-Kumar, Agnihotram V; Fadlallah, Bassam; Kessous, Roy; Cohen, Sabine; Lau, Susie; Salvador, Shannon; Gotlieb, Walter H

2017-04-01

To analyze the changes in the composition of the gynecologic oncology inpatient ward following the implementation of a robotic surgery program and its impact on inpatient resource utilization and costs. Retrospective review of the medical charts of patients admitted onto the gynecologic oncology ward the year prior to and five years after the implementation of robotics. The following variables were collected: patient characteristics, hospitalization details (reason for admission and length of hospital stay), and resource utilization (number of hospitalization days, consultations, and imaging). Following the introduction of robotic surgery, there were more admissions for elective surgery yet these accounted for only 21% of the inpatient ward in terms of number of hospital days, compared to 36% prior to the robotic program. This coincided with a sharp increase in the overall number of patients operated on by a minimally invasive approach (15% to 76%, p<0.0001). The cost per surgical admission on the inpatient ward decreased by 59% ($9827 vs. $4058) in the robotics era. The robotics program contributed to a ward with higher proportion of patients with complex comorbidities (Charlson≥5: RR 1.06), Stage IV disease (RR 1.30), and recurrent disease (RR 1.99). Introduction of robotic surgery allowed for more patients to be treated surgically while simultaneously decreasing inpatient resource use. With more patients with non-surgical oncological issues and greater medical complexity, the gynecologic oncology ward functions more like a medical rather than surgical ward after the introduction of robotics, which has implications for hospital-wide resource planning. Copyright © 2017 Elsevier Inc. All rights reserved.

Big data in oncologic imaging.

PubMed

Regge, Daniele; Mazzetti, Simone; Giannini, Valentina; Bracco, Christian; Stasi, Michele

2017-06-01

Cancer is a complex disease and unfortunately understanding how the components of the cancer system work does not help understand the behavior of the system as a whole. In the words of the Greek philosopher Aristotle "the whole is greater than the sum of parts." To date, thanks to improved information technology infrastructures, it is possible to store data from each single cancer patient, including clinical data, medical images, laboratory tests, and pathological and genomic information. Indeed, medical archive storage constitutes approximately one-third of total global storage demand and a large part of the data are in the form of medical images. The opportunity is now to draw insight on the whole to the benefit of each individual patient. In the oncologic patient, big data analysis is at the beginning but several useful applications can be envisaged including development of imaging biomarkers to predict disease outcome, assessing the risk of X-ray dose exposure or of renal damage following the administration of contrast agents, and tracking and optimizing patient workflow. The aim of this review is to present current evidence of how big data derived from medical images may impact on the diagnostic pathway of the oncologic patient.

Health education literacy in patients with chronic musculoskeletal diseases: development of a new questionnaire and sociodemographic predictors.

PubMed

Farin, Erik; Ullrich, Antje; Nagl, Michaela

2013-12-01

It was our aim to develop a questionnaire for patients with chronic musculoskeletal diseases to self-report their health education literacy, to analyse the psychometric properties of the instrument and to test hypotheses concerning sociodemographic predictors of health education literacy. A total of 577 patients with chronic back pain or osteoarthritis who underwent inpatient rehabilitation were surveyed. The resulting 'HELP questionnaire' (health education literacy of patients with chronic musculoskeletal diseases) consists of 18 items and three scales (comprehension of medical information, applying medical information, communicative competence in provider interactions). The instrument's psychometric properties are good (Cronbach's alpha between 0.88 and 0.95, unidimensionality and Rasch model fit established). Our sample's average level of self-reported health education literacy is quite high. However, 20-30% of the patients admitted to having difficulty understanding important aspects of health education programmes (i.e. comprehending what medical information means in relation to their disease). The variance explained by sociodemographic and basic medical variables is small (4-8%). Greater effort is required to make health education programmes easier to understand. There is a need for more research on interindividual variability of complex aspects of health literacy.

Medical student, nursing student, and non-health care respondents' implicit attitudes toward doctors and patients: Development and a pilot study of a new implicit attitudes test (IAT)

PubMed Central

Mazouni, Abdelhamid

2017-01-01

Introduction Medical educators have been concerned that medical students may decline in empathy for patients during the course of their training, based on studies measuring clinical empathy using psychometrically strong self-report measures. Clinical empathy is a complex construct, incorporating attitudes toward patients but also other components, such as professional detachment. Triangulation of extant measures with instruments based on nonreactive methods could provide a better understanding of whether and how physician attitudes toward patients may be changing during training. We sought to develop and pilot-test such a nonreactive method. Methods We develop variations of an implicit association test (IAT) designed to measure attitudes toward physicians and patients based on speed of reaction to images of actors and positive and negative words. In the IATs, the same actors are photographed as doctors, clinic outpatients, hospitalized inpatients, and as a “general public” control. We examine preliminary evidence for their validity by collecting pilot data from internet participants (not involved in the health professions), medical students, and nursing students. Results Internet participants (n = 314) and nursing students (n = 31) had more negative associations (IAT scores) with doctors than did medical students (n = 89); nursing students and female internet participants had more positive associations with hospitalized patients than did medical students and male internet participants. Medical students’ associations with hospitalized patients varied by year of training. Discussion This IAT may provide insight into implicit attitudes among those who enter training for the health profession and changes in those attitudes that may be inculcated during that training. PMID:28813524

Inhalational mold toxicity: fact or fiction? A clinical review of 50 cases.

PubMed

Khalili, Barzin; Montanaro, Marc T; Bardana, Emil J

2005-09-01

Three well-accepted mechanisms of mold-induced disease exist: allergy, infection, and oral toxicosis. Epidemiologic studies suggest a fourth category described as a transient aeroirritation effect. Toxic mold syndrome or inhalational toxicity continues to cause public concern despite a lack of scientific evidence that supports its existence. To conduct a retrospective review of 50 cases of purported mold-induced toxic effects and identify unrecognized conditions that could explain presenting symptoms; to characterize a subgroup with a symptom complex suggestive of an aeroirritation-mediated mechanism and compare this group to other diagnostic categories, such as sick building syndrome and idiopathic chemical intolerance; and to discuss the evolution of toxic mold syndrome from a clinical perspective. Eighty-two consecutive medical evaluations were analyzed of which 50 met inclusion criteria. These cases were critically reviewed and underwent data extraction of 23 variables, including demographic data, patient symptoms, laboratory, imaging, and pulmonary function test results, and an evaluation of medical diagnoses supported by medical record review, examination, and/or test results. Upper respiratory tract, lower respiratory tract, systemic, and neurocognitive symptoms were reported in 80%, 94%, 74%, and 84% of patients, respectively. Thirty patients had evidence of non-mold-related conditions that explained their presenting complaints. Two patients had evidence of allergy to mold allergens, whereas 1 patient exhibited mold-induced psychosis best described as toxic agoraphobia. Seventeen patients displayed a symptom complex that could be postulated to be caused by a transient mold-induced aeroirritation. The clinical presentation of patients with perceived mold-induced toxic effects is characterized by a disparate constellation of symptoms. Close scrutiny revealed a number of preexisting diagnoses that could plausibly explain presenting symptoms. The pathogenesis of aeroirritation implies completely transient symptoms linked to exposures at the incriminated site. Toxic mold syndrome represents the furtive evolution of aeroirritation from a transient to permanent symptom complex in patients with a psychogenic predisposition. In this respect, the core symptoms of toxic mold syndrome and their gradual transition to chronic symptoms related to nonspecific environmental fragrances and irritants appear to mimic what has been observed with other pseudodiagnostic categories, such as sick building syndrome and idiopathic chemical intolerance.

Barriers to medication adherence for the secondary prevention of stroke: a qualitative interview study in primary care.

PubMed

Jamison, James; Graffy, Jonathan; Mullis, Ricky; Mant, Jonathan; Sutton, Stephen

2016-08-01

Medications are highly effective at reducing risk of recurrent stroke, but success is influenced by adherence to treatment. Among survivors of stroke and transient ischaemic attack (TIA), adherence to medication is known to be suboptimal. To identify and report barriers to medication adherence for the secondary prevention of stroke/TIA. A qualitative interview study was conducted within general practice surgeries in the East of England, UK. Patients were approached by letter and invited to take part in a qualitative research study. Semi-structured interviews were undertaken with survivors of stroke, caregivers, and GPs to explore their perspectives and views around secondary prevention and perceived barriers to medication adherence. Key themes were identified using a grounded theory approach. Verbatim quotes describing the themes are presented here. In total, 28 survivors of stroke, including 14 accompanying caregivers and five GPs, were interviewed. Two key themes were identified. Patient level barriers included ability to self-care, the importance people attach to a stroke event, and knowledge of stroke and medication. Medication level barriers included beliefs about medication and beliefs about how pills work, medication routines, changing medications, and regimen complexity and burden of treatment. Patients who have had a stroke are faced with multiple barriers to taking secondary prevention medications in UK general practice. This research suggests that a collaborative approach between caregivers, survivors, and healthcare professionals is needed to address these barriers and facilitate medication-taking behaviour. © British Journal of General Practice 2016.

[Models of care and classification of "Children with special health care needs-CSHCN": Recommendations from the CSHCN Committee, Chilean Paediatric Society].

PubMed

Flores Cano, Juan Carlos; Lizama Calvo, Macarena; Rodríguez Zamora, Natalie; Ávalos Anguita, María Eugenia; Galanti De La Paz, Mónica; Barja Yañez, Salesa; Becerra Flores, Carlos; Sanhueza Sepúlveda, Carolina; Cabezas Tamayo, Ana María; Orellana Welch, Jorge; Zillmann Geerdts, Gisela; Antilef, Rosa María; Cox Melane, Alfonso; Valle Maluenda, Marcelo; Vargas Catalán, Nelson

2016-01-01

"Children with special health care needs" (CSHCN) is an emerging and heterogeneous group of paediatric patients, with a wide variety of medical conditions and with different uses of health care services. There is consensus on how to classify and assess these patients according to their needs, but not for their specific diagnosis. Needs are classified into 6 areas: a) specialised medical care; b) use or need of prescription medication; c) special nutrition; d) dependence on technology; e) rehabilitation therapy for functional limitation; and f) special education services. From the evaluation of each area, a classification for CSHCN is proposed according to low, medium, or high complexity health needs, to guide and distribute their care at an appropriate level of the health care system. Low complexity CSHCN should be incorporated into Primary Care services, to improve benefits for patients and families at this level. It is critical to train health care professionals in taking care of CSHCN, promoting a coordinated, dynamic and communicated work between different levels of the health care system. Compliance with these guidelines will achieve a high quality and integrated care for this vulnerable group of children. Copyright © 2016 Sociedad Chilena de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

Incorporating Geriatric Medicine Providers into the Care of the Older Adult with Cancer.

PubMed

Magnuson, Allison; Canin, Beverly; van Londen, G J; Edwards, Beatrice; Bakalarski, Pamela; Parker, Ira

2016-11-01

A significant proportion of cancer patients and survivors are age 65 and over. Older adults with cancer often have more complex medical and social needs than their younger counterparts. Geriatric medicine providers (GMPs) such as geriatricians, geriatric-trained advanced practice providers, and geriatric certified registered nurses have expertise in caring for older adults, managing complex medical situations, and optimizing function and independence for this population. GMPs are not routinely incorporated into cancer care for older adults; however, their particular skill set may add benefit at many points along the cancer care continuum. In this article, we review the role of geriatric assessment in the care of older cancer patients, highlight specific case scenarios in which GMPs may offer additional understanding and insight in the care of older adults with cancer, and discuss specific mechanisms for incorporating GMPs into oncology care.

[Guidelines for psychosocial care of cancer patients].

PubMed

Caminiti, Caterina

2013-01-01

Guidelines for psychosocial care of cancer patients. The Italian Association of Medical Oncologists published in 2013 the update of the first edition of the Psychosocial Guidelines for the care of cancer patients. The guidelines, produced by a multidisciplinary group (medical doctors, nurses, oncologists, psychologists and patients) aim at recognizing the importance of psychosocial care in helping the patients and their relatives to overcome the effects of the diagnosis and the treatments on mental health and emotional wellbeing. In some cases the evidences available are not as hard as those supporting drug treatments: many outcomes such as the effectiveness of educational interventions, the patients' wellbeing, thrust, perception of support, for their nature and complexity require both quantitative and qualitative measurements. Lack of robust evidences such as those obtained from clinical trials, does not necessarily correspond to lack of effectiveness of the intervention nor should make us forget that patients' rights (to good care, information and support) should be guaranteed.

Ethical issues in ocular genetics.

PubMed

Mezer, Eedy; Wygnanski-Jaffe, Tamara

2009-09-01

To review some of the major issues in ophthalmic genetics ethics: predictive testing, prenatal testing and abortion, gene therapy, confidentiality, payment for genetic testing, the duty to recontact patients and convey new information. Patients and families may perceive benefits even though genetic testing may be associated with adverse psychosocial outcomes. Most patients were in favor of prenatal diagnosis but opposed abortion. Patient selection as candidates for gene therapy should be based on the different clinical characteristics of each hereditary disease. The balance between the right of the patient for confidentiality and the best interest of family members or society is an ethical challenge. Most insurance companies will pay for genetic testing if the condition is hereditary. The duty to recontact patients when new medical information becomes available is still ethically controversial. The field of ocular genetics is ever growing involving complex medical, technical, financial and social issues. As a result, ethical issues are expected to become more common. Properly prepared medical professionals as well as unique counseling for participants and families may enable improved decision-making taking into consideration the needs of each individual.

An evaluation of early medication use for COPD: a population-based cohort study.

PubMed

Falk, Jamie; Dik, Natalia; Bugden, Shawn

2016-01-01

The aim of this study was to evaluate the first initiation, sequence of addition, and appropriate prescribing of COPD medications in Manitoba, Canada. A population-based cohort study of COPD medication use was conducted using administrative health care data (1997-2012). Those aged ≥35 years with COPD based on three or more COPD-related outpatient visits over a rolling 24-month window or at least one COPD-related hospitalization were included. The first medication(s) dispensed on or after the date of COPD diagnosis were determined based on pharmacy claims. The next medication(s) in sequence were determined to be additions or switches to the previous regimen. Evaluation of guideline-based appropriateness to receive inhaled corticosteroids (ICS) was based on exacerbation history and past medication use. Of 13,369 patients dispensed COPD medications after diagnosis, 66.0% were dispensed short-acting bronchodilators as first medications. Although long-acting bronchodilators alone were uncommonly used as first or subsequent medications, ICS were dispensed as first medications in 28.2% of patients. Over the study period, use of short-acting bronchodilators as first medications declined from 70.6% to 59.4% ( P <0.0001), whereas the use of ICS as a first medication increased from 23.5% to 34.4% ( P <0.0001). Dispensation of an ICS plus a long-acting β-agonist increased dramatically from 1.2% to 27.3% ( P <0.0001). By the end of the study period, the majority of patients (53.3%) were being initiated on two or more medications. Of 5,823 patients dispensed an ICS, 52.4% met Canadian guideline criteria for initiating an ICS, whereas 0.3% met Global Initiative for Chronic Obstructive Lung Disease guideline criteria. The use of first-line medications has declined over time, replaced primarily by combination inhalers prescribed early without prior trials of appropriate next step medications. This, along with an increasingly predominant use of multiple first medications, indicates a significant degree of medication burden in this already complex patient population.

[Ethics in anorexia nervosa: autonomy, beneficence or responsibility?].

PubMed

Figueroa, Gustavo

2008-05-01

In patients with anorexia nervosa, ethical dilemmas will appear in case of difficult and serious medical situations. Although the principle of beneficence could be used to argue for the use of coercive medical therapies, the respect for autonomy must take precedence. The latter is a central principle of bioethics. However, the interactions between autonomy, beneficence, non-maleficence, and justice become quite complex when these patients need to be treated. Difficulties must be overcome and a balance between these considerations must be reached. This paper gives an account of ethical values relevant to moral assessment in anorexia nervosa: conviction, responsibility and care.

Nosology, ontology and promiscuous realism.

PubMed

Binney, Nicholas

2015-06-01

Medics may consider worrying about their metaphysics and ontology to be a waste of time. I will argue here that this is not the case. Promiscuous realism is a metaphysical position which holds that multiple, equally valid, classification schemes should be applied to objects (such as patients) to capture different aspects of their complex and heterogeneous nature. As medics at the bedside may need to capture different aspects of their patients' problems, they may need to use multiple classification schemes (multiple nosologies), and thus consider adopting a different metaphysics to the one commonly in use. © 2014 John Wiley & Sons, Ltd.

Inferring Clinical Workflow Efficiency via Electronic Medical Record Utilization

PubMed Central

Chen, You; Xie, Wei; Gunter, Carl A; Liebovitz, David; Mehrotra, Sanjay; Zhang, He; Malin, Bradley

2015-01-01

Complexity in clinical workflows can lead to inefficiency in making diagnoses, ineffectiveness of treatment plans and uninformed management of healthcare organizations (HCOs). Traditional strategies to manage workflow complexity are based on measuring the gaps between workflows defined by HCO administrators and the actual processes followed by staff in the clinic. However, existing methods tend to neglect the influences of EMR systems on the utilization of workflows, which could be leveraged to optimize workflows facilitated through the EMR. In this paper, we introduce a framework to infer clinical workflows through the utilization of an EMR and show how such workflows roughly partition into four types according to their efficiency. Our framework infers workflows at several levels of granularity through data mining technologies. We study four months of EMR event logs from a large medical center, including 16,569 inpatient stays, and illustrate that over approximately 95% of workflows are efficient and that 80% of patients are on such workflows. At the same time, we show that the remaining 5% of workflows may be inefficient due to a variety of factors, such as complex patients. PMID:26958173

Avoiding Treatment Interruptions: What Role Do Australian Community Pharmacists Play?

PubMed Central

Abukres, Salem Hasn; Hoti, Kreshnik; Hughes, Jeffery David

2016-01-01

Objective To explore the reported practice of Australian community pharmacists when dealing with medication supply requests in absence of a valid prescription. Methods Self-administered questionnaire was posted to 1490 randomly selected community pharmacies across all Australian states and territories. This sample was estimated to be a 20% of all Australian community pharmacies. Results Three hundred eighty five pharmacists participated in the study (response rate achieved was 27.9% (there were 111 undelivered questionnaires). Respondents indicated that they were more likely to provide medications to regular customers without a valid prescription compared to non-regular customers (p<0.0001). However, supply was also influenced by the type of prescription and the medication requested. In the case of type of prescription (Standard, Authority or Private) this relates to the complexity/probability of obtaining a valid prescription from the prescriber at a later date (i.e. supply with an anticipated prescription). Decisions to supply and/or not supply related to medication type were more complex. For some cases, including medication with potential for abuse, the practice and/or the method of supply varied significantly according to age and gender of the pharmacist, and pharmacy location (p<0.05). Conclusions Although being a regular customer does not guarantee a supply, results of this study reinforce the importance for patients having a regular pharmacy, where pharmacists were more likely to continue medication supply in cases of patients presenting without a valid prescription. We would suggest, more flexible legislation should be implemented to allow pharmacists to continue supplying of medication when obtaining a prescription is not practical. PMID:27170997

Novel remote electronic medication supply model for opioid-dependent outpatients with polypharmacy--first long-term case study.

PubMed

Allemann, Samuel S; Dürsteler, Kenneth M; Strasser, Johannes; Vogel, Marc; Stoeckle, Marcel; Hersberger, Kurt E; Arnet, Isabelle

2017-08-16

Patients with substance use disorders grow older thanks to effective treatments. Together with a high prevalence of comorbidities, psychological problems, and low social support, these patients are at high risk for medication non-adherence. Established treatment facilities face challenges to accommodate these complex patients within their setting. Electronic medication management aids (e-MMAs) might be appropriate to simultaneously monitor and improve adherence for these patients. We report the first long-term experiences with a novel remote electronic medication supply model for two opioid-dependent patients with HIV. John (beginning dementia, 52 years, 6 tablets daily at 12 am) and Mary (frequent drug holidays, 48 years, 5-6 tablets daily at 8 pm) suffered from disease progression due to non-adherence. We electronically monitored adherence and clinical outcomes during 659 (John) and 953 (Mary) days between July 2013 and April 2016. Both patients retrieved over 90% of the pouches within 75 min of the scheduled time. Technical problems occurred in 4% (John) and 7.2% (Mary) of retrievals, but on-site support was seldom required. Viral loads fell below detection limits during the entire observation period. Continuous medication supply and persistence with treatment of over 1.7 years, timing adherence of more than 90%, and suppressed HIV viral load are first results supporting the feasibility of the novel supply model for patients on opioid-assisted treatment and polypharmacy.

Finding Meaning in Medication Reconciliation Using Electronic Health Records: Qualitative Analysis in Safety Net Primary and Specialty Care

PubMed Central

Matta, George Yaccoub; Khoong, Elaine C; Lyles, Courtney R; Schillinger, Dean

2018-01-01

Background Safety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication. Objective This mixed-methods observational study aimed to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions in a safety net system. Methods This study occurred 3 to 16 (median 9) months after new EHR implementation in five academic public hospital clinics. We video recorded visits between English-/Spanish-speaking patients and their primary/specialty care clinicians. We analyzed the proportion of medications addressed and coded time spent on nonverbal tasks during medication reconciliation as “multitasking EHR use,” “silent EHR use,” “non-EHR multitasking,” and “focused patient-clinician talk.” Finally, we analyzed communication patterns to develop a conceptual framework. Results We examined 35 visits (17%, 6/35 Spanish) between 25 patients (mean age 57, SD 11 years; 44%, 11/25 women; 48%, 12/25 Hispanic; and 20%, 5/25 with limited health literacy) and 25 clinicians (48%, 12/25 primary care). Patients had listed a median of 7 (IQR 5-12) relevant medications, and clinicians addressed a median of 3 (interquartile range [IQR] 1-5) medications. The median duration of medication reconciliation was 2.1 (IQR 1.0-4.2) minutes, comprising a median of 10% (IQR 3%-17%) of visit time. Multitasking EHR use occurred in 47% (IQR 26%-70%) of the medication reconciliation time. Silent EHR use and non-EHR multitasking occurred a smaller proportion of medication reconciliation time, with a median of 0% for both. Focused clinician-patient talk occurred a median of 24% (IQR 0-39%) of medication reconciliation time. Five communication patterns with EHR medication reconciliation were observed: (1) typical EHR multitasking for medication reconciliation, (2) dynamic EHR use to negotiate medication discrepancies, (3) focused patient-clinician talk for medication counseling and addressing patient concerns, (4) responding to patient concerns while maintaining EHR use, and (5) using EHRs to engage patients during medication reconciliation. We developed a conceptual diagram representing the dilemma of the multitasking clinician during medication reconciliation. Conclusions Safety net visits involve multitasking EHR use during almost half of medication reconciliation time. The multitasking clinician balances the cognitive and emotional demands posed by incoming information from multiple sources, attempts to synthesize and act on this information through EHR and communication tasks, and adopts strategies of silent EHR use and focused patient-clinician talk that may help mitigate the risks of multitasking. Future studies should explore diverse patient perspectives about clinician EHR multitasking, clinical outcomes related to EHR multitasking, and human factors and systems engineering interventions to improve the safety of EHR use during the complex process of medication reconciliation. PMID:29735477

Patient Safety Center Organization

DTIC Science & Technology

2006-06-01

Enterectomy Bariatric 7/20/05 4 hours/course (28 hours/year) Surgery R 7 Dr. Karen Horvath R5 Lap Enterectomy & Colectomy 11/30/05 4...areas in the UW Schools of Nursing and Dentistry, at the Harborview Research Center Microvascular Surgery lab, with the Seattle Children’s Hospital and...1 laboratory complex (2500 sq ft) has been designed within the University of Washington Medical Center, in the Surgery Pavilion complex

Diminished autonomic neurocardiac function in patients with generalized anxiety disorder.

PubMed

Kim, Kyungwook; Lee, Seul; Kim, Jong-Hoon

2016-01-01

Generalized anxiety disorder (GAD) is a chronic and highly prevalent disorder that is characterized by a number of autonomic nervous system symptoms. The purpose of this study was to investigate the linear and nonlinear complexity measures of heart rate variability (HRV), measuring autonomic regulation, and to evaluate the relationship between HRV parameters and the severity of anxiety, in medication-free patients with GAD. Assessments of linear and nonlinear complexity measures of HRV were performed in 42 medication-free patients with GAD and 50 healthy control subjects. In addition, the severity of anxiety symptoms was assessed using the State-Trait Anxiety Inventory and Beck Anxiety Inventory. The values of the HRV measures of the groups were compared, and the correlations between the HRV measures and the severity of anxiety symptoms were assessed. The GAD group showed significantly lower standard deviation of RR intervals and the square root of the mean squared differences of successive normal sinus intervals values compared to the control group ( P <0.01). The approximate entropy value, which is a nonlinear complexity indicator, was also significantly lower in the patient group than in the control group ( P <0.01). In correlation analysis, there were no significant correlations between HRV parameters and the severity of anxiety symptoms. The present study indicates that GAD is significantly associated with reduced HRV, suggesting that autonomic neurocardiac integrity is substantially impaired in patients with GAD. Future prospective studies are required to investigate the effects of pharmacological or non-pharmacological treatment on neuroautonomic modulation in patients with GAD.

Identifying Risk Factors for Elder Falls in Geriatric Rehabilitation in Israel.

PubMed

Ben Natan, Merav; Heyman, Neomi; Ben Israel, Joshua

2016-01-01

To identify risk factors for elder falls in a geriatric rehabilitation center in Israel. Retrospective chart review study. Four hundred and twelve medical records of inpatients in geriatric rehabilitation were retrospectively analyzed to compare between elders who sustained falls and those who did not. Of elders hospitalized during this year, 14% sustained falls. Fallers included a high proportion of males, with little comorbidity, not obese, and cardiovascular patients. Falls occurred frequently during patients' first week at the facility, mostly during the daytime. The falls occurred frequently in patients' rooms, and a common scenario was a fall during transition. The research findings single out patients who are allegedly at a lower risk of falls than more complex patients. Caregivers in geriatric rehabilitation settings should pay attention to patients who are allegedly at a lower risk of falls than more complex patients, and to cardiovascular patients in particular. © 2014 Association of Rehabilitation Nurses.

Multilevel analysis of the influence of patients' and general practitioners' characteristics on patented versus multiple-sourced statin prescribing in France.

PubMed

Pichetti, Sylvain; Sermet, Catherine; Godman, Brian; Campbell, Stephen M; Gustafsson, Lars L

2013-06-01

The French National Health Insurance and the Ministry of Health have introduced multiple reforms in recent years to increase prescribing efficiency. These include guidelines, academic detailing, financial incentives for the prescribing and dispensing of generics drugs as well as a voluntary pay-for-performance programme. However, the quality and efficiency of prescribing could be enhanced potentially if there was better understanding of the dynamics of prescribing behaviour in France. To analyse the patient and general practitioner characteristics that influence patented versus multiple-sourced statin prescribing in France. Statistical analysis was performed on the statin prescribing habits from 341 general practitioners (GPs) that were included in the IMS-Health Permanent Survey on Medical Prescription in France, which was conducted between 2009 and 2010 and involved 14,360 patients. Patient characteristics included their age and gender as well as five medical profiles that were constructed from the diagnoses obtained during consultations. These were (1) disorders of lipoprotein metabolism, (2) heart disease, (3) diabetes, (4) complex profiles and (5) profiles based on other diagnoses. Physician characteristics included their age, gender, solo or group practice, weekly workload and payment scheme. Patient age had a statistically significant impact on statin prescribing for patients in profile 1 (disorders of lipoprotein metabolism) and profile 3 (complex profiles) with a greater number of patented statins being prescribed for the youngest patients. For instance, patients older than 76 years with a complex profile were prescribed fewer patented statins than patients aged 68-76 years old with the same medical profile (coefficient: -0.225; p = 0.0008). By contrast, regardless of the patient's age, the medical profile did not affect the probability of prescribing a patented statin except in young patients with heart diseases who were prescribed a greater number of patented statins (coefficient: 0.3992; p = 0.0007). Prescribing was also statistically influenced by physician features, e.g., older male physicians were more likely to prescribe patented statins (coefficient: 0.245; p = 0.0417) and GPs practicing in groups were more likely to prescribe multiple sourced statins (coefficient: -0.178; p = 0.0338), which is an important finding of the study. GPs with a lower workload prescribed a greater number of patented statins. There is significant variability in the prescribing of different statins among patient and physician profiles as well as between solo and group practices. Consequently, there are opportunities to target demand-side measures to enhance the prescribing of multiple-sourced statins. Further studies are warranted, in particular in other therapeutic classes, to provide a counter-balance to the considerable marketing activities of pharmaceutical companies.

Can a collaborative healthcare network improve the care of people with epilepsy?

PubMed

Shamim, Ejaz A; Mane, Ketan; Loddenkemper, Tobias; Leviton, Alan

2018-05-01

New opportunities are now available to improve care in ways not possible previously. Information contained in electronic medical records can now be shared without identifying patients. With network collaboration, large numbers of medical records can be searched to identify patients most like the one whose complex medical situation challenges the physician. The clinical effectiveness of different treatment strategies can be assessed rapidly to help the clinician decide on the best treatment for this patient. Other capabilities from different components of the network can prompt the recognition of what is the best available option and encourage the sharing of information about programs and electronic tools. Difficulties related to privacy, harmonization, integration, and costs are expected, but these are currently being addressed successfully by groups of organizations led by those who recognize the benefits. Copyright © 2018 Elsevier Inc. All rights reserved.

The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for Diverse Populations

PubMed Central

Chan, Lenny L. S.; Fouts, Michelle M.; Murphy, Elizabeth J.

2017-01-01

Widespread electronic health record (EHR) implementation creates new challenges in the diabetes care of complex and diverse populations, including safe medication prescribing for patients with limited health literacy and limited English proficiency. This review highlights how the EHR electronic prescribing transformation has affected diabetes care for vulnerable patients and offers recommendations for improving patient safety through EHR electronic prescribing design, implementation, policy, and research. Specifically, we present evidence for (1) the adoption of RxNorm; (2) standardized naming and picklist options for high alert medications such as insulin; (3) the widespread implementation of universal medication schedule and language-concordant labels, with the expansion of electronic prescription 140-character limit; (4) enhanced bidirectional communication with pharmacy partners; and (5) informatics and implementation research in safety net healthcare systems to examine how EHR tools and practices affect diverse vulnerable populations. PMID:28197420

The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for Diverse Populations.

PubMed

Ratanawongsa, Neda; Chan, Lenny L S; Fouts, Michelle M; Murphy, Elizabeth J

2017-01-01

Widespread electronic health record (EHR) implementation creates new challenges in the diabetes care of complex and diverse populations, including safe medication prescribing for patients with limited health literacy and limited English proficiency. This review highlights how the EHR electronic prescribing transformation has affected diabetes care for vulnerable patients and offers recommendations for improving patient safety through EHR electronic prescribing design, implementation, policy, and research. Specifically, we present evidence for (1) the adoption of RxNorm; (2) standardized naming and picklist options for high alert medications such as insulin; (3) the widespread implementation of universal medication schedule and language-concordant labels, with the expansion of electronic prescription 140-character limit; (4) enhanced bidirectional communication with pharmacy partners; and (5) informatics and implementation research in safety net healthcare systems to examine how EHR tools and practices affect diverse vulnerable populations.

An analytics approach to designing patient centered medical homes.

PubMed

Ajorlou, Saeede; Shams, Issac; Yang, Kai

2015-03-01

Recently the patient centered medical home (PCMH) model has become a popular team based approach focused on delivering more streamlined care to patients. In current practices of medical homes, a clinical based prediction frame is recommended because it can help match the portfolio capacity of PCMH teams with the actual load generated by a set of patients. Without such balances in clinical supply and demand, issues such as excessive under and over utilization of physicians, long waiting time for receiving the appropriate treatment, and non-continuity of care will eliminate many advantages of the medical home strategy. In this paper, by using the hierarchical generalized linear model with multivariate responses, we develop a clinical workload prediction model for care portfolio demands in a Bayesian framework. The model allows for heterogeneous variances and unstructured covariance matrices for nested random effects that arise through complex hierarchical care systems. We show that using a multivariate approach substantially enhances the precision of workload predictions at both primary and non primary care levels. We also demonstrate that care demands depend not only on patient demographics but also on other utilization factors, such as length of stay. Our analyses of a recent data from Veteran Health Administration further indicate that risk adjustment for patient health conditions can considerably improve the prediction power of the model.

Patient compliance based on genetic medicine: a literature review.

PubMed

Schneider, Kai Insa; Schmidtke, Jörg

2014-01-01

For this literature review, medical literature data bases were searched for studies on patient compliance after genetic risk assessment. The review focused on conditions where secondary or tertiary preventive options exist, namely cancer syndromes (BRCA-related cancer, HNPCC/colon cancer), hemochromatosis, thrombophilia, smoking cessation, and obesity. As a counterpart, patient compliance was assessed regarding medication adherence and medical advice in some of the most epidemiologically important conditions (including high blood pressure, metabolic syndrome, and coronary heart disease) after receiving medical advice based on nongenetic risk information or a combination of genetic and nongenetic risk information. In the majority of studies based on genetic risk assessments, patients were confronted with predictive rather than diagnostic genetic profiles. Most of the studies started from a knowledge base around 10 years ago when DNA testing was at an early stage, limited in scope and specificity, and costly. The major result is that overall compliance of patients after receiving a high-risk estimate from genetic testing for a given condition is high. However, significant behavior change does not take place just because the analyte is "genetic." Many more factors play a role in the complex process of behavioral tuning. Without adequate counseling and guidance, patients may interpret risk estimates of predictive genetic testing with an increase in fear and anxiety.

Company Profile: GenesFX Health Pty Ltd.

PubMed

Sheffield, Leslie J; Rogers, Edith

2011-07-01

GenesFX Health (Melbourne, Australia) is providing genetic testing with clinical interpretation to personalize how people take medications. The company's aim is to achieve the best health outcomes for patients by ensuring that the way they metabolize medications is included when doctors prescribe them medication. This would be achieved by introducing pharmacogenomics into medical practice to provide more informed prescribing, reduce side effects and create maximum efficacy of medications. Through the use of GenesFX Health innovative genetic test, DNAdose ® , GenesFX Health is able to analyze the profile of a patient's genetic variation and maps this to the optimum drug and dosage for a specific treatment. The company's focus on the interpretation of genetic test results has led to the development of a Pharmacogenomic Database and Pharmacogenomic Interpretation System, which allows the team to communicate complex genetic test results in a meaningful way to doctors. There is a significant opportunity to expand GenesFX Health current model of delivering pharmacogenomic tests, by partnering with other laboratories around the world, making pharmacogenomics more accessible and clinically useful. Doctors using the service have welcomed the clinical guidance. Patients have felt relieved and empowered by understanding why they have adverse reactions to medications, and which medications and doses are most suited to them.

Factors associated with adherence to medication among depressed patients from Saudi Arabia: a cross-sectional study

PubMed Central

Al Jumah, Khalaf; Hassali, Mohamed Azmi; Al Qhatani, Dalal; El Tahir, Kamal

2014-01-01

Background Several studies have investigated the factors associated with adherence to antidepressants, with inconsistent conclusions. However, no similar study has investigated this issue among patients diagnosed with major depressive disorder in Saudi Arabia. The aim of this study is to explore patients’ adherence to antidepressant medications, and the factors associated with adherence. Methods A non-experimental cross-sectional design was used to measure adherence to antidepressants among major depressive disorder patients, and the factors associated with adherence. The patients were recruited from the outpatient clinic at the Al-Amal Complex for Mental Health in Riyadh, Saudi Arabia, between August 2013 and January 2014. Eligible participants met with one of the research coordinators for assessment of their adherence. Adherence was investigated indirectly by use of the Morisky Medication Adherence Scale, and patients’ beliefs were assessed through the Beliefs about Medicine Questionnaire. Information about the severity of their depression, demographics, and other study variables were collected. Results A total of 403 patients met the inclusion criteria and participated in the study. Of those, 203 (50.37%) were females, while the remaining 200 (49.6%) were males. There was an average age of 39 years (standard deviation, ±11 years). Half of the patients (52.9%) reported low adherence to their antidepressant medication, with statistically significant differences between the low adherence and high adherence scores relating to sex, age, and duration of illness. Conclusion Low medication adherence is a common problem among major depressive disorder patients in Saudi Arabia. Medication-taking behavior among depressed patients is influenced by several factors, mainly patients’ beliefs regarding antidepressants. This study has improved the understanding of the factors associated with adherence to antidepressants. PMID:25378929

TBI Patient, Injury, Therapy, and Ancillary Treatments Associated with Outcomes at Discharge and 9 Months Post-discharge

PubMed Central

Horn, Susan D.; Corrigan, John D.; Beaulieu, Cynthia L.; Bogner, Jennifer; Barrett, Ryan S.; Giuffrida, Clare G.; Ryser, David K.; Cooper, Kelli; Carroll, Deborah M.; Deutscher, Daniel

2015-01-01

Objective To examine associations of patient and injury characteristics, inpatient rehabilitation therapy activities, and neurotropic medications with outcomes at discharge and 9 months post-discharge for patients with traumatic brain injury (TBI) Design Prospective, longitudinal observational study Setting 10 inpatient rehabilitation centers (9 US, 1 Canada) Participants Consecutive patients (n=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after an index TBI injury Interventions Not applicable Main Outcome Measures Rehabilitation length of stay, discharge to home, and Functional Independence Measure (FIM) at discharge and 9 months post-discharge Results The admission FIM Cognitive score was used to create 5 relatively homogeneous subgroups for subsequent analysis of treatment outcomes. Within each subgroup, significant associations were found between outcomes and patient and injury characteristics, time spent in therapy activities, and medications used. Patient and injury characteristics explained on average 35.7% of the variation in discharge outcomes and 22.3% in 9-month outcomes. Adding time spent and level of effort in therapy activities, as well as percent of stay using specific medications, explained approximately 20.0% more variation for discharge outcomes and 12.9% for 9-month outcomes. After patient, injury, and treatment characteristics were used to predict outcomes, center differences added only approximately 1.9% additional variance explained. Conclusions At discharge, greater effort during therapy sessions, time spent in more complex therapy activities, and use of specific medications were associated with better outcomes for patients in all admission FIM Cognitive subgroups. At 9 months post-discharge, similar but less pervasive associations were observed for therapy activities, but not classes of medications. Further research is warranted to examine more specific combinations of therapy activities and medications that are associated with better outcomes. PMID:26212406

Reliability of medical record abstraction by non-physicians for orthopedic research.

PubMed

Mi, Michael Y; Collins, Jamie E; Lerner, Vladislav; Losina, Elena; Katz, Jeffrey N

2013-06-09

Medical record review (MRR) is one of the most commonly used research methods in clinical studies because it provides rich clinical detail. However, because MRR involves subjective interpretation of information found in the medical record, it is critically important to understand the reproducibility of data obtained from MRR. Furthermore, because medical record review is both technically demanding and time intensive, it is important to establish whether trained research staff with no clinical training can abstract medical records reliably. We assessed the reliability of abstraction of medical record information in a sample of patients who underwent total knee replacement (TKR) at a referral center. An orthopedic surgeon instructed two research coordinators (RCs) in the abstraction of inpatient medical records and operative notes for patients undergoing primary TKR. The two RCs and the surgeon each independently reviewed 75 patients' records and one RC reviewed the records twice. Agreement was assessed using the proportion of items on which reviewers agreed and the kappa statistic. The kappa for agreement between the surgeon and each RC ranged from 0.59 to 1 for one RC and 0.49 to 1 for the other; the percent agreement ranged from 82% to 100% for one RC and 70% to 100% for the other. The repeated abstractions by the same RC showed high intra-rater agreement, with kappas ranging from 0.66 to 1 and percent agreement ranging from 97% to 100%. Inter-rater agreement between the two RCs was moderate with kappa ranging from 0.49 to 1 and percent agreement ranging from 76% to 100%. The MRR method used in this study showed excellent reliability for abstraction of information that had low technical complexity and moderate to good reliability for information that had greater complexity. Overall, these findings support the use of non-surgeons to abstract surgical data from operative notes.

A pragmatic randomized comparative effectiveness trial of transitional care for a socioeconomically diverse population: Design, rationale and baseline characteristics.

PubMed

Schaeffer, Christine; Teter, Caroline; Finch, Emily A; Hurt, Courtney; Keeter, Mary Kate; Liss, David T; Rogers, Angela; Sheth, Avani; Ackermann, Ronald

2018-02-01

Transitional care programs have been widely used to reduce readmissions and improve the quality and safety of the handoff process between hospital and outpatient providers. Very little is known about effective transitional care interventions among patients who are uninsured or with Medicaid. This paper describes the design and baseline characteristics of a pragmatic randomized comparative effectiveness trial of transitional care. Northwestern Medical Group- Transitional Care (NMG-TC) care model was developed to address the needs of patients with multiple medical problems that required lifestyle changes and were amenable to office-based management. We present the design, evaluation methods and baseline characteristics of NMG-TC trial patients. Baseline demographic characteristics indicate that our patient population is predominantly male, Medicaid insured and non-white. This study will evaluate two methods for implementing an effective transitional care model in a medically complex and socioeconomically diverse population. Copyright © 2017 Elsevier Inc. All rights reserved.

Complex regional pain syndrome of the upper extremity.

PubMed

Patterson, Ryan W; Li, Zhongyu; Smith, Beth P; Smith, Thomas L; Koman, L Andrew

2011-09-01

The diagnosis and management of complex regional pain syndrome is often challenging. Early diagnosis and intervention improve outcomes in most patients; however, some patients will progress regardless of intervention. Multidisciplinary management facilitates care in complex cases. The onset of signs and symptoms may be obvious or insidious; temporal delay is a frequent occurrence. Difficulty sleeping, pain unresponsive to narcotics, swelling, stiffness, and hypersensitivity are harbingers of onset. Multimodal treatment with hand therapy, sympatholytic drugs, and stress loading may be augmented with anesthesia blocks. If the dystrophic symptoms are controllable by medications and a nociceptive focus or nerve derangement is correctable, surgery is an appropriate alternative. Chronic sequelae of contracture may also be addressed surgically in patients with controllable sympathetically maintained pain. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Linked Orders Improve Safety in Scheduling and Administration of Chemotherapeutic Agents

PubMed Central

Whipple, Nancy; Boulware, Joy; Danca, Kala; Boyarin, Kirill; Ginsberg, Eliot; Poon, Eric; Sweet, Micheal; Schade, Sue; Rogala, Jennifer

2010-01-01

The pharmacologic treatment for cancer must adhere to complex, finely orchestrated treatment plans, including not only chemotherapy medications, but pre/post-hydration, anti-emetics, anti-anxiety, and other medications that are given before, during and after chemotherapy doses. The treatment plans specify the medications and dictate precise dosing, frequency, and timing. This is a challenge to most Computerized Physician Order Entry (CPOE), Pharmacy and Electronic Medication Administration record (eMAR) Systems. Medications are scheduled on specific dates, referred to as chemo days, from the onset of the treatment, and precisely timed on the designated chemo day. For patients enrolled in research protocols, the adherence to the defined schedule takes on additional import, since variation is a violation of the protocol. If the oncologist determines that medications must be administered outside the defined constraints, the patient must be un-enrolled from the protocol and the course of therapy is re-written. Pharmacy and eMAR systems utilized in processing chemotherapy medications must be able to support the intricate relationships between each drug defined in the treatment plans. PMID:21347104

Current Situation of Medication Adherence in Hypertension.

PubMed

Vrijens, Bernard; Antoniou, Sotiris; Burnier, Michel; de la Sierra, Alejandro; Volpe, Massimo

2017-01-01

Despite increased awareness, poor adherence to treatments for chronic diseases remains a global problem. Adherence issues are common in patients taking antihypertensive therapy and associated with increased risks of coronary and cerebrovascular events. Whilst there has been a gradual trend toward improved control of hypertension, the number of patients with blood pressure values above goal has remained constant. This has both personal and economic consequences. Medication adherence is a multifaceted issue and consists of three components: initiation, implementation, and persistence. A combination of methods is recommended to measure adherence, with electronic monitoring and drug measurement being the most accurate. Pill burden, resulting from free combinations of blood pressure lowering treatments, makes the daily routine of medication taking complex, which can be a barrier to optimal adherence. Single-pill fixed-dose combinations simplify the habit of medication taking and improve medication adherence. Re-packing of medication is also being utilized as a method of improving adherence. This paper presents the outcomes of discussions by a European group of experts on the current situation of medication adherence in hypertension.

How to buy a medical home? Policy options and practical questions.

PubMed

Berenson, Robert A; Rich, Eugene C

2010-06-01

In this paper, we describe a range of payment options to support the PCMH, identifying their conceptual strengths and weaknesses. These include enhanced FFS payment for office visits to the PCMH; paying additional FFS for "new" PCMH services; variations of traditional FFS combined with new PCMH-oriented per patient per month capitation; and combined capitation payments for traditional primary care medical services as well as new medical home services. In discussing options for PCMH payment reform we consider issues in patient severity adjustment, performance payment, and the role of payments to community service organizations to collaborate with the PCMH. We also highlight some of the practical challenges that can complicate reimbursement reform for primary care and the PCMH. Through this discussion we identify key dimensions to provider payment reform relevant to promoting enhanced primary care through the patient centered medical home. These consist of paying for the basic medical home services, rewarding excellent performance of medical homes, incentivizing medical home connections to other community health care resources, and overcoming implementation challenges to medical home payments. Each of these overarching policy issues invokes a substantial subset of policy relevant research questions that collectively comprise a robust research agenda. We conclude that the conceptual strengths and weaknesses of available payment models for medical home functions invoke a complex array of options with varying levels of real-world feasibility. The different needs of patients and communities, and varying characteristics of practices must also be factors guiding PCMH payment reform. Indeed, it may be that different circumstances will require different payment approaches in various combinations.

How to Buy a Medical Home? Policy Options and Practical Questions

PubMed Central

Berenson, Robert A.

2010-01-01

In this paper, we describe a range of payment options to support the PCMH, identifying their conceptual strengths and weaknesses. These include enhanced FFS payment for office visits to the PCMH; paying additional FFS for “new” PCMH services; variations of traditional FFS combined with new PCMH-oriented per patient per month capitation; and combined capitation payments for traditional primary care medical services as well as new medical home services. In discussing options for PCMH payment reform we consider issues in patient severity adjustment, performance payment, and the role of payments to community service organizations to collaborate with the PCMH. We also highlight some of the practical challenges that can complicate reimbursement reform for primary care and the PCMH. Through this discussion we identify key dimensions to provider payment reform relevant to promoting enhanced primary care through the patient centered medical home. These consist of paying for the basic medical home services, rewarding excellent performance of medical homes, incentivizing medical home connections to other community health care resources, and overcoming implementation challenges to medical home payments. Each of these overarching policy issues invokes a substantial subset of policy relevant research questions that collectively comprise a robust research agenda. We conclude that the conceptual strengths and weaknesses of available payment models for medical home functions invoke a complex array of options with varying levels of real-world feasibility. The different needs of patients and communities, and varying characteristics of practices must also be factors guiding PCMH payment reform. Indeed, it may be that different circumstances will require different payment approaches in various combinations. PMID:20467911

Which Reasons Do Doctors, Nurses, and Patients Have for Hospital Discharge? A Mixed-Methods Study

PubMed Central

Ubbink, Dirk T.; Tump, Evelien; Koenders, Josje A.; Kleiterp, Sieta; Goslings, J. Carel; Brölmann, Fleur E.

2014-01-01

Background The decision to discharge a patient from a hospital is a complex process governed by many medical and non-medical factors, while the actual reasons for discharge frequently remain ill-defined. Aim To define relevant discharge criteria as perceived by doctors, nurses and patients for the development of a standard hospital discharge policy, we collected actual reasons and most pivotal medical and organisational criteria for discharge among all stakeholders. Setting A tertiary referral university teaching hospital. Methods We conducted a mixed methods analysis, using patient questionnaires, interviews and a focus group with caregivers, and observations during the daily rounds of doctors, nurses and patients during their hospital stay. Fourteen wards of the Surgery, Paediatrics and Neurology departments contributed. Results We observed 426 patients during their hospital stay. Forty doctors and nurses were interviewed, and 7 senior nurses attended a focus group. The most commonly used discharge criteria were clinical factors, organisational discharge issues and patient-related factors. A total of 269 patients returned their questionnaires. About one third of the adult patients and nearly half of the children (or their parents) felt their personal situation and assistance needed at home was insufficiently taken into account before discharge. Patients were least satisfied with the information given about what they were allowed to do or should avoid after discharge and their involvement in the planning of their discharge. Thus, besides obvious medical reasons for discharge, several non-medical reasons were signalled by all stakeholders as important issues to be improved. Conclusions A set of discharge criteria could be defined that is useful for a more uniform hospital discharge policy that may help reduce unnecessary length of stay and improve patient satisfaction. PMID:24625666

Healthcare Reimbursement and Quality Improvement: Integration Using the Electronic Medical Record

PubMed Central

Britton, John R.

2015-01-01

Reimbursement for healthcare has utilized a variety of payment mechanisms with varying degrees of effectiveness. Whether these mechanisms are used singly or in combination, it is imperative that the resulting systems remunerate on the basis of the quantity, complexity, and quality of care provided. Expanding the role of the electronic medical record (EMR) to monitor provider practice, patient responsiveness, and functioning of the healthcare organization has the potential to not only enhance the accuracy and efficiency of reimbursement mechanisms but also to improve the quality of medical care. PMID:26340397

Medication-related cognitive artifacts used by older adults with heart failure

PubMed Central

Mickelson, Robin S.; Willis, Matt; Holden, Richard J.

2015-01-01

Objective To use a human factors perspective to examine how older adult patients with heart failure use cognitive artifacts for medication management. Methods We performed a secondary analysis of data collected from 30 patients and 14 informal caregivers enrolled in a larger study of heart failure self-care. Data included photographs, observation notes, interviews, video recordings, medical record data, and surveys. These data were analyzed using an iterative content analysis. Results Findings revealed that medication management was complex, inseparable from other patient activities, distributed across people, time, and place, and complicated by knowledge gaps. We identified fifteen types of cognitive artifacts including medical devices, pillboxes, medication lists, and electronic personal health records used for: 1) measurement/evaluation; 2) tracking/communication; 3) organization/administration; and 4) information/sensemaking. These artifacts were characterized by fit and misfit with the patient’s sociotechnical system and demonstrated both advantages and disadvantages. We found that patients often modified or “finished the design” of existing artifacts and relied on “assemblages” of artifacts, routines, and actors to accomplish their self-care goals. Conclusions Cognitive artifacts are useful but sometimes are poorly designed or are not used optimally. If appropriately designed for usability and acceptance, paper-based and computer-based information technologies can improve medication management for individuals living with chronic illness. These technologies can be designed for use by patients, caregivers, and clinicians; should support collaboration and communication between these individuals; can be coupled with home-based and wearable sensor technology; and must fit their users’ needs, limitations, abilities, tasks, routines, and contexts of use. PMID:26855882

Domestic Minor Sex Trafficking Patients: A Retrospective Analysis of Medical Presentation.

PubMed

Goldberg, Amy P; Moore, Jessica L; Houck, Christopher; Kaplan, Dana M; Barron, Christine E

2017-02-01

To describe the clinical characteristics of patients referred for domestic minor sex trafficking (DMST) to improve identification and intervention. Retrospective cohort study. The Lawrence A. Aubin, Sr Child Protection Center at Hasbro Children's Hospital where patients are evaluated by child abuse pediatricians in outpatient, emergency department, and inpatient settings. A total of 41 patients younger than the age of 18 years referred for the evaluation of DMST involvement between August 1, 2013 and March 30, 2015. We collected demographic, social-environmental, medical, and psychiatric variables from the medical records of patients referred for evaluation who have self-disclosed, been reported with evidence, and/or have histories that place them at high risk for DMST involvement. Children had frequent contact with medical providers, with 81% seen in the year before referral for DMST. Childhood maltreatment and family dysfunction were identified (sexual abuse, 21/37 or 57%; parental substance abuse, 22/37 or 60%) in the 41 patients. Children had medical problems (eg, sexually transmitted infection, 13/41 or 32%), psychiatric needs (eg, acute suicidality, 8/41 or 20%; at least 1 previous psychiatric admission, 19/41 or 46%), and substance use (36/41 or 88%). Although 26/41 (63%) had runaway and 17/41 (42%) lived in a group home placement, 28/41 (68%) currently lived at home and 29/41 (71%) presented with a parent/guardian or relative. Children referred for DMST present frequently to physicians and have complex medical and psychiatric needs. Medical providers' increased awareness of this health issue would inform victim identification and intervention. Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Professionalism and maintenance of certification: using vignettes describing interpersonal dilemmas to stimulate reflection and learning.

PubMed

Bernabeo, Elizabeth C; Reddy, Siddharta G; Ginsburg, Shiphra; Holmboe, Eric S

2014-01-01

Physicians do not always agree on "rules" governing behavior in professionally challenging situations. Little is known about contextual factors that influence physician approaches in these situations. We explored the individual-, social-, and societal-level factors that physicians consider when responding to 2 common professional dilemmas. We were particularly interested in knowing the extent to which physicians engage in self-reflection as a result of responding to the vignettes. A cross-sectional Web-based survey was sent to a random sample of 396 physicians, prompting them to respond to scripted professional dilemmas. A total of 120 physicians responded, yielding a response rate of 32.6%. Physicians responded to these dilemmas in highly variable ways, negotiating a complex array of contextual factors in their decisions. Interacting factors involving individual-level physician (eg, worry, guilt), patient (eg, nature of medical condition or relationship with patient), and social/societal (eg, policy, what peers or colleagues do) were important drivers in physician responses. Qualitative analysis revealed that several interacting themes guide physician approaches to professional dilemmas: patient welfare; types of patients; political, ethical, or legal issues; guiding principles; values; rules; and habits. Physicians negotiate a complex set of individual-, social-, and societal-level factors in response to professional dilemmas. This finding has important implications for the promotion and assessment of professional behavior in practicing physicians. Reflecting on scenarios may be an opportunity for physicians to learn about how and why they make decisions in difficult situations. © 2014 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education.

Screening for Cystic Fibrosis-Related Diabetes: Matching Pathophysiology and Addressing Current Challenges.

PubMed

Boudreau, Valérie; Reynaud, Quitterie; Dubois, Catherine Lehoux; Coriati, Adèle; Desjardins, Katherine; Durieu, Isabelle; Rabasa-Lhoret, Rémi

2016-10-01

Nearly 50% of adult patients with cystic fibrosis (CF) have diabetes. The occurrence of CF-related diabetes (CFRD) is preceded and is associated with deterioration of lung function and nutritional status. Microvascular complications can occur, but the main cause of death is respiratory failure rather than cardiovascular causes as in type 1 or type 2 diabetes. Because other methods such as glycated hemoglobin (A1C) levels are less sensitive in patients with CF, the recommended screening test is the oral glucose tolerance test (OGTT) with a 75 g glucose dose. However, OGTT is poorly suited for patients with CF, who are already facing a high disease-care burden, and appropriate CF-glucose cut-off for diagnosis and prognosis are also questioned. Thus, alternative screening methods are compared to the classical test (2-hour OGTT), including shorter OGTTs and continuous glucose monitoring. Moreover, many challenges complicate the screening for diabetes such as the complex medical care time for a patient, which is reflected by low adherence to screening tests. The best screening test should take into account the particularities of CFRD and the complexity of the CF medical care. Copyright © 2016 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Medical emergencies in children of orthodox Jehovah's Witness families: Three recent legal cases, ethical issues and proposals for management.

PubMed

Guichon, Juliet; Mitchell, Ian

2006-12-01

Three recent Canadian legal cases have dealt with the proposed blood transfusion of adolescent members of Jehovah's Witness (JW) families. In each case, the court permitted transfusions if medically necessary. Much critical analysis of the issue of forced treatment of decisionally competent adolescents focuses exclusively on competence and questions why mature minors may not decide for themselves. The authors argue that a focus on decision-making competence alone is too narrow. Before one may legally give or refuse consent to medical treatment, three conditions must be met: competence, adequate information and lack of coercion. In striving to find agreement on medical treatment, physicians, patients and JW family members seek and, in fact, often achieve mutual understanding and cooperation. Coercion by actual or threatened shunning and excommunication can occur, and these factors may affect adolescent decision-making. In this context, a court order authorizing medical treatment can, therefore, be seen as enhancing patient freedom. The authors suggest that, in addition to fulfilling existing statutory duties to report a child in need of protection, health care professionals caring for acute patients of JW families should actively look for evidence that the patient has accurate medical information and is acting without coercion. The authors also explore suggestions on how to deal with the unusual complexities of such cases.

Project EASE: a study to test a psychosocial model of epilepsy medication managment.

PubMed

DiIorio, Collen; Shafer, Patricia Osborne; Letz, Richard; Henry, Thomas R; Schomer, Donal L; Yeager, Kate

2004-12-01

The purpose of this study was to test a psychosocial model of medication self-management among people with epilepsy. This model was based primarily on social cognitive theory and included personal (self-efficacy, outcome expectations, goals, stigma, and depressive symptoms), social (social support), and provider (patient satisfaction and desire for control) variables. Participants for the study were enrolled at research sites in Atlanta, Georgia, and Boston, Massachusetts and completed computer-based assessments that included measures of the study variables listed above. The mean age of the 317 participants was 43.3 years; about 50% were female, and 81%white. Self-efficacy and patient satisfaction explained the most variance in medication management. Social support was related to self-efficacy; stigma to self-efficacy and depressive symptoms; and self-efficacy to outcome expectations and depressive symptoms. Findings reinforce that medication-taking behavior is affected by a complex set of interactions among psychosocial variables.

Building Structured Personal Health Records from Photographs of Printed Medical Records.

PubMed

Li, Xiang; Hu, Gang; Teng, Xiaofei; Xie, Guotong

2015-01-01

Personal health records (PHRs) provide patient-centric healthcare by making health records accessible to patients. In China, it is very difficult for individuals to access electronic health records. Instead, individuals can easily obtain the printed copies of their own medical records, such as prescriptions and lab test reports, from hospitals. In this paper, we propose a practical approach to extract structured data from printed medical records photographed by mobile phones. An optical character recognition (OCR) pipeline is performed to recognize text in a document photo, which addresses the problems of low image quality and content complexity by image pre-processing and multiple OCR engine synthesis. A series of annotation algorithms that support flexible layouts are then used to identify the document type, entities of interest, and entity correlations, from which a structured PHR document is built. The proposed approach was applied to real world medical records to demonstrate the effectiveness and applicability.

Building Structured Personal Health Records from Photographs of Printed Medical Records

PubMed Central

Li, Xiang; Hu, Gang; Teng, Xiaofei; Xie, Guotong

2015-01-01

Personal health records (PHRs) provide patient-centric healthcare by making health records accessible to patients. In China, it is very difficult for individuals to access electronic health records. Instead, individuals can easily obtain the printed copies of their own medical records, such as prescriptions and lab test reports, from hospitals. In this paper, we propose a practical approach to extract structured data from printed medical records photographed by mobile phones. An optical character recognition (OCR) pipeline is performed to recognize text in a document photo, which addresses the problems of low image quality and content complexity by image pre-processing and multiple OCR engine synthesis. A series of annotation algorithms that support flexible layouts are then used to identify the document type, entities of interest, and entity correlations, from which a structured PHR document is built. The proposed approach was applied to real world medical records to demonstrate the effectiveness and applicability. PMID:26958219

Patients' webs of relations in the medical landscapes of Central Ukraine.

PubMed

Kołodziejska-Degórska, Iwona

2016-08-01

Village dwellers in Central Ukraine have access to various types of therapy that comprise diverse medical landscapes. Patients' movements within these landscapes are possible thanks to each person's web of relations. Medical landscapes are not fixed, but vary and dynamically change for each person, depending on their fluid and interchanging, hierarchical webs of mutual relations with other people, personal bodies, institutions, discourses, political powers, other non-human organisms, or objects such as medicines. This paper was inspired by the medicoscape concept (Hörbst and Krause 2004 ) as well as Ingold's idea of meshwork analyses of relations between various actors: in this case, patients, healers, a weak state, official healthcare providers, pharmacists and medicinal plants, in the context of patients' therapeutic choices. Self-medication based on herbal remedies is a very important feature of people's medical landscapes in Central Ukraine and usually the first therapy choice for most interlocutors. That is why this paper is focused on the presentation of the means through which people acquire knowledge about medicinal plants, and the ways they interact with plants and plants interact with them. In this way, showing the complexity of villagers' webs of relations is possible. The analysis is based on ethnographic research conducted between 2009 and 2013 in the Vinnytsia region (Central Ukraine).

Ventriculostomy Simulation Using Patient-Specific Ventricular Anatomy, 3D Printing, and Hydrogel Casting.

PubMed

Ryan, Justin R; Chen, Tsinsue; Nakaji, Peter; Frakes, David H; Gonzalez, L Fernando

2015-11-01

Educational simulators provide a means for students and experts to learn and refine surgical skills. Educators can leverage the strengths of medical simulators to effectively teach complex and high-risk surgical procedures, such as placement of an external ventricular drain. Our objective was to develop a cost-effective, patient-derived medical simulacrum for cerebral lateral ventriculostomy. A cost-effective, patient-derived medical simulacrum was developed for placement of an external lateral ventriculostomy. Elastomeric and gel casting techniques were used to achieve realistic brain geometry and material properties. 3D printing technology was leveraged to develop accurate cranial properties and dimensions. An economical, gravity-driven pump was developed to provide normal and abnormal ventricular pressures. A small pilot study was performed to gauge simulation efficacy using a technology acceptance model. An accurate geometric representation of the brain was developed with independent lateral cerebral ventricular chambers. A gravity-driven pump pressurized the ventricular cavities to physiologic values. A qualitative study illustrated that the simulation has potential as an educational tool to train medical professionals in the ventriculostomy procedure. The ventricular simulacrum can improve learning in a medical education environment. Rapid prototyping and multi-material casting techniques can produce patient-derived models for cost-effective and realistic surgical training scenarios. Copyright © 2015 Elsevier Inc. All rights reserved.

Epidemiologic study of epilepsy in young Singaporean men.

PubMed

Kun, L N; Ling, L W; Wah, Y W; Lian, T T

1999-10-01

This survey of 20,542 Singaporean men born in 1974 studied the clinical features of young men diagnosed with epilepsy on preenlistment screening. All male citizens in Singapore are medically screened at age 18 years before enlistment for compulsory military service. Patients suspected to have epilepsy are then referred to government hospitals for further management. We interviewed the patients and their parents and reviewed their hospital records. Eighty-nine patients with epilepsy were identified, indicating a lifetime prevalence of 4.9/1,000 males by age 18 years. The lifetime prevalence of epilepsy among Chinese, Malays, and Indians were 5.2, 2.8, and 6.4/1,000, respectively; these differences were not statistically significant. The mean age of seizure onset was 11.1 years. Generalized seizures (65.2%) were commoner than partial seizures (34.8%); common seizure types included generalized tonic-clonic seizures (52.8%), complex partial seizures with secondary generalization (24.7%), and myoclonic seizures (5.6%). Common epileptic syndromes included temporal lobe epilepsy (16.9%), juvenile myoclonic epilepsy (5.6%), and frontal lobe epilepsy (2.2%). Eighty-four (94.4%) patients sought medical treatment, and seven (7.9%) patients sought additional traditional treatment. Although 70 (78.7%) patients responded to medication, 14 (15.7%) patients remained refractory to treatment. The lifetime prevalence of epilepsy in young Singaporean men was 4.9/1,000. The majority (65.2%) had generalized seizures. Temporal lobe epilepsy was the commonest (16.9%) defined epilepsy syndrome. More patients with epilepsy (94.4%) sought medical treatment, although 15.7% remained refractory to medication.

Current status of cannabis treatment of multiple sclerosis with an illustrative case presentation of a patient with MS, complex vocal tics, paroxysmal dystonia, and marijuana dependence treated with dronabinol.

PubMed

Deutsch, Stephen I; Rosse, Richard B; Connor, Julie M; Burket, Jessica A; Murphy, Mary E; Fox, Fiona J

2008-05-01

Pain, spasticity, tremor, spasms, poor sleep quality, and bladder and bowel dysfunction, among other symptoms, contribute significantly to the disability and impaired quality of life of many patients with multiple sclerosis (MS). Motor symptoms referable to the basal ganglia, especially paroxysmal dystonia, occur rarely and contribute to the experience of distress. A substantial percentage of patients with MS report subjective benefit from what is often illicit abuse of extracts of the Cannabis sativa plant; the main cannabinoids include delta-9-tetrahydrocannabinol (delta9-THC) and cannabidiol. Clinical trials of cannabis plant extracts and synthetic delta9-THC provide support for therapeutic benefit on at least some patient self-report measures. An illustrative case is presented of a 52-year-old woman with MS, paroxysmal dystonia, complex vocal tics, and marijuana dependence. The patient was started on an empirical trial of dronabinol, an encapsulated form of synthetic delta9-THC that is usually prescribed as an adjunctive medication for patients undergoing cancer chemotherapy. The patient reported a dramatic reduction of craving and illicit use; she did not experience the "high" on the prescribed medication. She also reported an improvement in the quality of her sleep with diminished awakenings during the night, decreased vocalizations, and the tension associated with their emission, decreased anxiety and a decreased frequency of paroxysmal dystonia.

Data-Driven Healthcare: Challenges and Opportunities for Interactive Visualization.

PubMed

Gotz, David; Borland, David

2016-01-01

The healthcare industry's widespread digitization efforts are reshaping one of the largest sectors of the world's economy. This transformation is enabling systems that promise to use ever-improving data-driven evidence to help doctors make more precise diagnoses, institutions identify at risk patients for intervention, clinicians develop more personalized treatment plans, and researchers better understand medical outcomes within complex patient populations. Given the scale and complexity of the data required to achieve these goals, advanced data visualization tools have the potential to play a critical role. This article reviews a number of visualization challenges unique to the healthcare discipline.

Information environments for supporting consistent registrar medical handover.

PubMed

Alem, Leila; Joseph, Michele; Kethers, Stefanie; Steele, Cathie; Wilkinson, Ross

This study was two-fold in nature. Initially, it examined the information environment and the use of customary information tools to support medical handovers in a large metropolitan teaching hospital on four weekends (i.e. Friday night to Monday morning). Weekend medical handovers were found to involve sequences of handovers where patients were discussed at the discretion of the doctor handing over; no reliable discussion of all patients of concern occurred at any one handover, with few information tools being used; and after a set of weekend handovers, there was no complete picture on a Monday morning without an analysis of all patient progress notes. In a subsequent case study, three information tools specifically designed as intervention that attempted to enrich the information environment were evaluated. Results indicate that these tools did support greater continuity in who was discussed but not in what was discussed at handover. After the intervention, if a doctor discussed a patient at handover, that patient was more likely to be discussed at subsequent handovers. However, the picture at Monday morning remained fragmentary. The results are discussed in terms of the complexities inherent in the handover process.

Giving rheumatology patients online home access to their electronic medical record (EMR): advantages, drawbacks and preconditions according to care providers.

PubMed

van der Vaart, Rosalie; Drossaert, Constance H C; Taal, Erik; van de Laar, Mart A F J

2013-09-01

Technology enables patients home access to their electronic medical record (EMR), via a patient portal. This study aims to analyse (dis)advantages, preconditions and suitable content for this service, according to rheumatology health professionals. A two-phase policy Delphi study was conducted. First, interviews were performed with nurses/nurse practitioners (n = 9) and rheumatologists (n = 13). Subsequently, collected responses were quantified, using a questionnaire among the interviewees. The following advantages of patient home access to the EMR were reported: (1) enhancement of patient participation in treatment, (2) increased knowledge and self-management, (3) improved patient-provider interaction, (4) increased patient safety, and (5) better communication with others. Foreseen disadvantages of the service included: (1) problems with interpretation of data, (2) extra workload, (3) a change in consultation content, and (4) disturbing the patient-provider interaction. Also, the following preconditions emerged from the data: (1) optimal security, (2) no extra record, but a patient-accessible section, (3) no access to clinical notes, and (4) a lag time on the release of lab data. Most respondents reported that data on diagnosis, medication, treatment plan and consultations could be released to patients. On releasing more complex data, such as bodily examinations, lab results and radiological images the opinions differed considerably. Providing patients home access to their medical record might be a valuable next step into patient empowerment and in service towards the patient, provided that security is optimal and content and presentation of data are carefully considered.

Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans.

PubMed

Vaughan Sarrazin, Mary; Rosenthal, Gary E; Turvey, Carolyn L

2018-06-12

Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients. © Health Research and Educational Trust.

Goal-setting in clinical medicine.

PubMed

Bradley, E H; Bogardus, S T; Tinetti, M E; Inouye, S K

1999-07-01

The process of setting goals for medical care in the context of chronic disease has received little attention in the medical literature, despite the importance of goal-setting in the achievement of desired outcomes. Using qualitative research methods, this paper develops a theory of goal-setting in the care of patients with dementia. The theory posits several propositions. First, goals are generated from embedded values but are distinct from values. Goals vary based on specific circumstances and alternatives whereas values are person-specific and relatively stable in the face of changing circumstances. Second, goals are hierarchical in nature, with complex mappings between general and specific goals. Third, there are a number of factors that modify the goal-setting process, by affecting the generation of goals from values or the translation of general goals to specific goals. Modifying factors related to individuals include their degree of risk-taking, perceived self-efficacy, and acceptance of the disease. Disease factors that modify the goal-setting process include the urgency and irreversibility of the medical condition. Pertinent characteristics of the patient-family-clinician interaction include the level of participation, control, and trust among patients, family members, and clinicians. The research suggests that the goal-setting process in clinical medicine is complex, and the potential for disagreements regarding goals substantial. The nature of the goal-setting process suggests that explicit discussion of goals for care may be necessary to promote effective patient-family-clinician communication and adequate care planning.

Preoperative therapeutic apheresis for severe medically refractory amiodarone-induced thyrotoxicosis: a case report.

PubMed

Yamamoto, Jennifer; Dostmohamed, Hanifa; Schacter, Isanne; Ariano, Robert E; Houston, Donald S; Lewis, Brenda; Knoll, Colleen; Katz, Pamela; Zarychanski, Ryan

2014-06-01

Amiodarone is associated with thyroid dysfunction and life-threatening thyrotoxicosis. In medically refractory cases, or where medical therapy is contraindicated, thyroidectomy may be required. To decrease perioperative thyroid storm and to reduce overall surgical risk, apheresis may be considered preoperatively to restore euthyroidism. We report a 46-year-old female with a history of cardiac arrhythmia and tachycardia-induced cardiomyopathy for which she received amiodarone. Months after discontinuation of amiodarone, the patient presented with wide complex tachycardia and symptoms of thyrotoxicosis. Laboratory testing confirmed severe thyrotoxicosis which was subsequently refractory to medical therapy. Total thyroidectomy was required. Following a total of 10 apheresis treatments, thyroid hormone levels were reduced to near normal levels and the patient's symptoms improved. Thyroidectomy was performed without intraoperative or postoperative complication. In the setting of life-threatening, medically refractory amiodarone-induced thyrotoxicosis, therapeutic apheresis can effectively reduce thyroid hormone levels and restore a state of clinical and biochemical euthyroidism. © 2013 Wiley Periodicals, Inc.

The China Patient-Centred Evaluative Assessment of Cardiac Events (China PEACE)-Prospective Study of 3-Vessel Disease: rationale and design

PubMed Central

Rao, Chenfei; Bongiovanni, Tasce; Li, Xi; Gao, Huawei; Zhang, Heng; Li, Jing; Zhao, Yan; Yuan, Xin; Hua, Kun; Hu, Shengshou; Krumholz, Harlan M; Jiang, Lixin; Zheng, Zhe

2016-01-01

Introduction Complex coronary artery disease (left main and three-vessel disease) carries high risks of adverse events and cost burden. However, in China, little is known about which patients are directed toward which treatment strategies and what outcomes are being achieved. Methods and analysis Using the China PEACE (Patient-centered Evaluative Assessment of Cardiac Events) research network, this prospective study of three-Vessel Disease, the China PEACE-3VD study, has a plan to consecutively register over 4000 patients with a diagnosis of 3VD and/or left-main disease by elective coronary angiography at 24 large cardiovascular centres in China. We centrally conducted medical record abstraction and SYNTAX Score calculation for all registered patients. The sites invited patients to the prospective cohort, and conducted 1-year follow-up on major events, including cardiac events, symptoms, secondary prevention and quality of life. The estimated entire sample size of eligible patients of 4000 was determined based on both feasibility and consideration of adequate statistical precision for describing the treatment decisions, guidelines adherence and appropriateness of treatment for patients with complex coronary artery diseases. The study is designed to investigate patient, clinician and hospital factors associated with each treatment strategy (percutaneous coronary intervention, coronary artery bypass grafting or medical therapy) as well as appropriateness of treatment choice, current guideline compliance and patient-reported outcomes for patients with complex coronary artery disease in large cardiovascular centres in China, as a foundation for enhanced knowledge in the field and to assist quality improvement initiatives. Ethics and dissemination The study protocol was approved by the ethics committee at the China National Center for Cardiovascular Diseases. Findings will be shared with participating hospitals, policymakers and the academic community, to promote quality monitoring, quality improvement and the efficient allocation, and use of coronary revascularisation procedures in China. Trial registration number NCT01625312; Pre-results PMID:26880670

Transatlantic medical consultation and second opinion in pediatric cardiology has benefit past patient care: A case study in videoconferencing.

PubMed

Kovacikova, Lubica; Zahorec, Martin; Skrak, Peter; Hanna, Brian D; Lee Vogel, R

2017-07-01

Telemedicine is a rapidly evolving form of modern information and communication technology used to deliver clinical services and educational activities. The aim of this article is to report and analyze our experience with transatlantic consultation via videoconferencing in pediatric cardiology. In February, 2013, videoconferencing project was launched between a medium-volume pediatric cardiac center in Bratislava, Slovakia and subspecialty experts from a high-volume pediatric cardiac program at The Children's Hospital of Philadelphia (CHOP), USA. During 1.5-2 hours videoconferences, 2-3 patients with similar complex clinical scenarios were presented to CHOP experts. The main goal of the project was consultation on individual patients to validate, alter or radically change clinical management plans. From February, 2013 to January, 2017, 25 videoconferences occurred and 73 cases were discussed. The median patient age was 52 months (range; 1 day-30 years). Forty-six discussed cases were outpatients, 21 patients were in the intensive care unit and 6 patients were discussed post mortem. Thirty-one CHOP experts from different subspecialties participated actively in patient consultations. The most frequent recommendations were related to single ventricle, pulmonary hypertension or heart failure patients and intervention in complex and/or rare cardiac diseases. Specialists from CHOP agreed completely with the original care plan in 16% of cases. In 52% cases, adjustments to original plan were suggested. Radical changes were recommended in 30% of cases. Receiving institution adopted recommendations to the patient care fully in 79% and partially in 13% of patients. Based on our 4-year experience we consider videoconferencing between medium-size pediatric cardiac center and subspecialty experts from a high-volume pediatric cardiac program a suitable form of medical consultations. Videoconferencing assists in clinical decision making for complex patient cases and serves as an effective educational tool to gain knowledge and experience "without borders." © 2017 Wiley Periodicals, Inc.

Completion of Limitation of Medical Treatment forms by junior doctors for patients with dementia: clinical, medicolegal and education perspectives.

PubMed

Yoong, Jaclyn; MacPhail, Aleece; Trytel, Gael; Rajendram, Prashanti Yalini; Winbolt, Margaret; Ibrahim, Joseph E

2017-10-01

Objective Limitation of Medical Treatment (LMT) forms are an essential element of end-of-life care. Decision making around LMT is complex and often involves patients with dementia. Despite the complexity, junior doctors frequently play a central role in completing LMT forms. The present study sought perspectives from a range of stakeholders (hospital clinicians, medical education personnel, legal and advocacy staff) about junior doctors' roles in completing LMT forms in general and for patients with dementia. Methods Qualitative data were gathered in semi-structured interviews (SSI) and theoretical concepts were explored in roundtable discussion (RD). Participants were recruited through purposive and convenience sampling drawing on healthcare and legal personnel employed in the public hospital and aged care systems, selected from major metropolitan hospitals, healthcare and legal professional bodies and advocacy organisations in Victoria, Australia. The contents of the SSIs and RD were subject to thematic analysis using a framework approach. Data were indexed according to the topics established in the study aim; categories were systematically scrutinised, from which key themes were distilled. Results Stakeholders reported that completing LMT forms was difficult for junior doctors because of a lack of medical and legal knowledge, as well as clinical inexperience and inadequate training. Healthcare organisations (HCOs) either lacked policies about the role of junior doctors or had practices that were discordant with policy. In this process, there were substantial gaps pertaining to patients with dementia. Recommendations made by the study participants included the provision of supervised clinical exposure and additional training for junior doctors, strengthening HCO policies and explicit consideration of the needs of patients with dementia. Conclusions LMT forms should be designed for clarity and consistency across HCOs. Enhancing patient care requires appropriate and sensitive completion of LMT. Relevant HCO policy and clinical practice changes are discussed herein, and recommendations are made for junior doctors in this arena, specifically in the context of patients with dementia. What is known about the topic? Junior doctors continue to play a central role in LMT orders, a highly complex decision-making task that they are poorly prepared to complete. LMT decision making in Australia's aging population and for people with dementia is especially challenging. What does this paper add? A broad range of stakeholders, including hospital clinicians, medical education personnel and legal and advocacy staff, identified ongoing substantial gaps in education and training of junior doctors (despite what is already known in the literature). Furthermore, LMT decision making for patients with dementia is not explicitly considered in policy of practice. What are the implications for practitioners? Current policy and practice are not at the desired level to deliver appropriate end-of-life care with regard to LMT orders, especially for patients with dementia. Greater involvement of executives and senior clinicians is required to improve both practice at the bed side and the training and support of junior doctors, as well as creating more robust policy.

Lifestyle and Self-Management by Those Who Live It: Patients Engaging Patients in a Chronic Disease Model.

PubMed

Jesse, Michelle T; Rubinstein, Elizabeth; Eshelman, Anne; Wee, Corinne; Tankasala, Mrunalini; Li, Jia; Abouljoud, Marwan

Patients pursuing organ transplantation have complex medical needs, undergo comprehensive evaluation for possible listing, and require extensive education. However, transplant patients and their supports frequently report the need for more lifestyle and self-management strategies for living with organ transplantation. First, to explore feasibility of a successful, patient-run transplant lifestyle educational group (Transplant Living Community), designed to complement medical care and integrated into the clinical setting; and second, to report the major themes of patients' and supports' qualitative and quantitative feedback regarding the group. Informal programmatic review and patient satisfaction surveys. A total of 1862 patient satisfaction surveys were disseminated and 823 were returned (response rate, 44.2%). Patients and their supports reported positive feedback regarding the group, including appreciation that the volunteer was a transplant recipient and gratitude for the lifestyle information. Five areas were associated with the success of Transplant Living Community: 1) a "champion" dedicated to the program and its successful integration into a multidisciplinary team; 2) a health care environment receptive to integration of a patient-led group with ongoing community development; 3) a high level of visibility to physicians and staff, patients, and supports; 4) a clearly presented and manageable lifestyle plan ("Play Your ACES"(a) [Attitude, Compliance, Exercise, and Support]), and 5) a strong volunteer structure with thoughtful training with the ultimate objective of volunteers taking ownership of the program. It is feasible to integrate a sustainable patient-led lifestyle and self-management educational group into a busy tertiary care clinic for patients with complex chronic illnesses.

Codes of medical ethics: traditional foundations and contemporary practice.

PubMed

Sohl, P; Bassford, H A

1986-01-01

The Hippocratic Coprus recognized the interaction of 'business' and patient-health moral considerations, and urged that the former be subordinated to the latter. During the 1800s with the growth of complexity in both scientific knowledge and the organization of health services, the medical ethical codes addressed themselves to elaborate rules of conduct to be followed by the members of the newly emerging national medical associations. After World War II the World Medical Association was established as an international forum where national medical associations could debate the ethical problems presented by modern medicine. The International Code of Medical ethics and the Declaration of Geneva were written as 20th century restatements of the medical profession's commitment to the sovereignty of the patient-care norm. Many ethical statements have been issued by the World Medical Association in the past 35 years; they show the variety and difficulties of contemporary medical practice. The newest revisions were approved by the General Assembly of the World Medical Association in Venice, Italy October 1983. Their content is examined and concern is voiced about the danger of falling into cultural relativism when questions about the methods of financing medical services are the subject of an ethical declaration which is arrived at by consensus in the W.M.A.

En route care patient safety: thoughts from the field.

PubMed

McNeill, Margaret M; Pierce, Penny; Dukes, Susan; Bridges, Elizabeth J

2014-08-01

The purpose of this study was to describe the patient safety culture of en route care in the United States Air Force aeromedical evacuation system. Almost 100,000 patients have been transported since 2001. Safety concerns in this unique environment are complex because of the extraordinary demands of multitasking, time urgency, long duty hours, complex handoffs, and multiple stressors of flight. An internet-based survey explored the perceptions and experiences of safety issues among nursing personnel involved throughout the continuum of aeromedical evacuation care. A convenience sample of 236 nurses and medical technicians from settings representing the continuum was studied. Descriptive and nonparametric statistics were used to analyze the quantitative data, and thematic analysis was applied to the qualitative data. Results indicate that over 90% of respondents agree or strongly agree safety is a priority in their unit and that their unit is responsive to patient safety initiatives. Many respondents described safety incidents or near misses, and these have been categorized as personnel physical capability limitations, environmental threats, medication and equipment issues, and care process problems. Results suggest the care of patients during transport is influenced by the safety culture, human factors, training, experience, and communication. Suggestions to address safety issues emerged from the survey data. Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.

Which interventions are used by health care professionals to enhance medication adherence in cardiovascular patients? A survey of current clinical practice.

PubMed

Berben, Lut; Bogert, Laura; Leventhal, Marcia E; Fridlund, Bengt; Jaarsma, Tiny; Norekvål, Tone M; Smith, Karen; Strömberg, Anna; Thompson, David R; De Geest, Sabina

2011-03-01

Complex medication regimens are often required to manage cardiovascular diseases. As non-adherence, which can have severe negative outcomes, is common among cardiovascular patients, various interventions to improve adherence should be implemented in daily practice. To assess which strategies cardiovascular nurses and allied health professionals utilize to (1) assess patients' adherence to medication regimen, and (2) enhance medication adherence via educational/cognitive, counseling/behavioral, and psychological/affective interventions. A 45-item questionnaire to assess adherence assessment and interventional strategies utilized by health care professionals in daily clinical practice was distributed to a convenience sample of attendants of the 10th Annual Spring Meeting of the European Society of Cardiology Council on Cardiovascular Nursing and Allied Professions conference in Geneva (Switzerland) in March 2010. Respondents not in direct clinical practice were excluded. Descriptive statistics were used to describe practice patterns regarding adherence management. Of 276 distributed questionnaires, 171 (62%) were returned, of which 34 (20%) were excluded as respondents performed no direct patient care. Questioning patients about non-adherence during follow-up was the most frequently reported assessment strategy (56%). Educational/cognitive adherence enhancing interventions were used most frequently, followed by counseling/behavioral interventions. Psychological/affective interventions were less frequently used. The most frequent intervention used was providing reading materials (66%) followed by training patients regarding medication taking during inpatient recovery (48%). Slightly over two-thirds (69%) reported using a combination of interventions to improve patient's adherence. Educational interventions are used most in clinical practice, although evidence shows they are less effective than behavioral interventions at enhancing medication adherence. Copyright © 2010 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

[Physician perspectives on the impact of patient preferences and the role of next-of-kin of patients in evidence-based decision-making: A qualitative interview study from oncology].

PubMed

Salloch, Sabine; Otte, Ina C; Reinacher-Schick, Anke; Vollmann, Jochen

2018-04-01

The impact of patient preferences in evidence-based medicine is a complex issue which touches on theoretical questions as well as medical practice in the clinical context. The interaction between evidence-based recommendations and value-related patient preferences in clinical practice is, however, highly complex and requires not only medical knowledge but social, psychological and communicative competencies on the side of the physician. The multi-layered process of oncology physicians' clinical decision-making was explored in 14 semi-structured interviews with respect to a first diagnosis of a pancreatic adenocarcinoma. A case vignette was used and the Q method ("card sorting") was applied to analyze the influence of different factors (such as evidence, patient preferences and the role of relatives) on physicians' deliberations. Content analysis (Mayring) was performed. The results show that the participating oncologists consider patient preferences as an important guidance which, however, is limited on certain occasions where the physicians assume a leadership role in decision-making. From the interviewees' perspectives, the preferences of the patients' relatives are likewise of high importance because debilitating oncologic treatments can only be carried out if patients have both social and psychological support. There is a need for an ongoing reflection of the physicians' own values and due consideration of the patients' social role within the context of shared decision-making. Copyright © 2018. Published by Elsevier GmbH.

Mobile technology supporting trainee doctors’ workplace learning and patient care: an evaluation

PubMed Central

2013-01-01

Background The amount of information needed by doctors has exploded. The nature of knowledge (explicit and tacit) and processes of knowledge acquisition and participation are complex. Aiming to assist workplace learning, Wales Deanery funded “iDoc”, a project offering trainee doctors a Smartphone library of medical textbooks. Methods Data on trainee doctors’ (Foundation Year 2) workplace information seeking practice was collected by questionnaire in 2011 (n = 260). iDoc baseline questionnaires (n = 193) collected data on Smartphone usage alongside other workplace information sources. Case reports (n = 117) detail specific instances of Smartphone use. Results Most frequently (daily) used information sources in the workplace: senior medical staff (80% F2 survey; 79% iDoc baseline); peers (70%; 58%); and other medical/nursing team staff (53% both datasets). Smartphones were used more frequently by males (p < 0.01). Foundation Year 1 (newly qualified) was judged the most useful time to have a Smartphone library because of increased responsibility and lack of knowledge/experience. Preferred information source varied by question type: hard copy texts for information-based questions; varied resources for skills queries; and seniors for more complex problems. Case reports showed mobile technology used for simple (information-based), complex (problem-based) clinical questions and clinical procedures (skills-based scenarios). From thematic analysis, the Smartphone library assisted: teaching and learning from observation; transition from medical student to new doctor; trainee doctors’ discussions with seniors; independent practice; patient care; and this ‘just-in-time’ access to reliable information supported confident and efficient decision-making. Conclusion A variety of information sources are used regularly in the workplace. Colleagues are used daily but seniors are not always available. During transitions, constant access to the electronic library was valued. It helped prepare trainee doctors for discussions with their seniors, assisting the interchange between explicit and tacit knowledge. By supporting accurate prescribing and treatment planning, the electronic library contributed to enhanced patient care. Trainees were more rapidly able to medicate patients to reduce pain and more quickly call for specific assessments. However, clinical decision-making often requires dialogue: what Smartphone technology can do is augment, not replace, discussion with their colleagues in the community of practice. PMID:23336964

[Asthenic syndrome in clinical course of acute period of brain concussion during complex treatment using nootropic agents].

PubMed

Tkachov, A V

2008-01-01

The comparative analysis of a complex examination of 108 persons aged from 16 till 60 years in acute period of closed craniocerebral injury (CCCT) has been done. Every participants have been divided into 2 groups depending on a nootrop medication they receive in a complex treatment. A control group consisted of 30 practically healthy people. Objective examination by means of tests was done on the 1-st, 10-th that 30-th day of treatment. Patients of 1-st (37 persons) group received piracetam in complex treatment and patients of the 2-nd group (71 persons) pramistar. Patients of the first group received a base treatment (analgetics, tranquilizers, vitamins of group B, magnesium sulfate, diuretic preparations) as well as piracetam at dosage 0.2, two tablets three times per day. The Patients of the 2-nd group received a base treatment as well as pramistar at dosage 0.6, one tablet 2 times per day. Specially developed multiaspects scales and questionnaires, MRT of the brain and EEG have been used for objectification of patient, complaints. During a complex clinico-neuropsychological examination it was found that all cases of concussion of the brain are accompanied by those or other asthenic disorders.

Slowing and Loss of Complexity in Alzheimer's EEG: Two Sides of the Same Coin?

PubMed Central

Dauwels, Justin; Srinivasan, K.; Ramasubba Reddy, M.; Musha, Toshimitsu; Vialatte, François-Benoît; Latchoumane, Charles; Jeong, Jaeseung; Cichocki, Andrzej

2011-01-01

Medical studies have shown that EEG of Alzheimer's disease (AD) patients is “slower” (i.e., contains more low-frequency power) and is less complex compared to age-matched healthy subjects. The relation between those two phenomena has not yet been studied, and they are often silently assumed to be independent. In this paper, it is shown that both phenomena are strongly related. Strong correlation between slowing and loss of complexity is observed in two independent EEG datasets: (1) EEG of predementia patients (a.k.a. Mild Cognitive Impairment; MCI) and control subjects; (2) EEG of mild AD patients and control subjects. The two data sets are from different patients, different hospitals and obtained through different recording systems. The paper also investigates the potential of EEG slowing and loss of EEG complexity as indicators of AD onset. In particular, relative power and complexity measures are used as features to classify the MCI and MiAD patients versus age-matched control subjects. When combined with two synchrony measures (Granger causality and stochastic event synchrony), classification rates of 83% (MCI) and 98% (MiAD) are obtained. By including the compression ratios as features, slightly better classification rates are obtained than with relative power and synchrony measures alone. PMID:21584257

[Laser therapy and famotidine in complex restorative treatment of primary chronic gastroduodenitis].

PubMed

Filimonov, R M; Musaeva, O M

2003-01-01

Primary chronic gastroduodenitis (PCG) is one of the most frequent diseases of the gastrointestinal tract. Timely and efficient treatment of patients with PCG promotes ulcer prevention. In this connection, an urgent problem of restorative medicine is to develop medical programs with active introduction of pharmacophysiotherapeutic complexes, in particular, laser therapy and anti-secretory preparation (famotidine) that increase therapeutic efficacy of treatment of this disease. To this end, we give results of treatment of 50 patients with primary chronic gastroduodenitis (26 having undergone laser therapy only, and 24 having had a combination of laser therapy and famotidine), which demonstrated that the complex action method has a more adequate effect on pathogenetic components in this disease than monotherapy.

The effect of illustrations on patient comprehension of medication instruction labels.

PubMed

Hwang, Stephen W; Tram, Carolyn Q N; Knarr, Nadia

2005-06-16

Labels with special instructions regarding how a prescription medication should be taken or its possible side effects are often applied to pill bottles. The goal of this study was to determine whether the addition of illustrations to these labels affects patient comprehension. Study participants (N = 130) were enrolled by approaching patients at three family practice clinics in Toronto, Canada. Participants were asked to interpret two sets of medication instruction labels, the first with text only and the second with the same text accompanied by illustrations. Two investigators coded participants' responses as incorrect, partially correct, or completely correct. Health literacy levels of participants were measured using a validated instrument, the REALM test. All participants gave a completely correct interpretation for three out of five instruction labels, regardless of whether illustrations were present or not. For the two most complex labels, only 34-55% of interpretations of the text-only version were completely correct. The addition of illustrations was associated with improved performance in 5-7% of subjects and worsened performance in 7-9% of subjects. The commonly-used illustrations on the medication labels used in this study were of little or no use in improving patients' comprehension of the accompanying written instructions.

HIV, disease plague, demoralization and "burnout": resident experience of the medical profession in Nairobi, Kenya.

PubMed

Raviola, Giuseppe; Machoki, M'Imunya; Mwaikambo, Esther; Good, Mary Jo DelVecchio

2002-03-01

This paper describes the experiences of physicians-in-training at a public hospital in Nairobi, Kenya, where medical professionals practice in an environment characterized by both significant lack of resources and patients with HIV/AIDS in historically unprecedented numbers. The data reported here are part of a larger study examining ethical dilemmas in medical education and practice among physicians in East Africa. A questionnaire and semi-structured interview were completed by fifty residents in four medical specialties, examining social and emotional supports, personal and professional sources of stress, emotional numbing and disengagement from patients and peers, and symptoms of post-traumatic stress and depression. The factors affecting resident well-being are found in this study to be more complex than previous interviews suggested. This study highlights the fact that as a result of working in an environment characterized by poor communication among hospital staff as well as a lack of resources and high numbers of patients with HIV/AIDS, residents' perceptions of themselves--their technical proficiency, their ability to care and feel for others and themselves, and for some their entire sense of self--are significantly affected. Also affected are the patients they work to treat.

Framework for Smart Electronic Health Record- Linked Predictive Models to Optimize Care for Complex Digestive Diseases

DTIC Science & Technology

2015-03-01

data against previous published outcomes in AP and Chronic Pancreatitis (CP). This served as useful validation of our data set before entering the...These patients can develop multiple complications from their disease. In addition, the treatments for CD (both medical and surgical ) can impose...years of diagnosis. The treatment for CD can sometimes involve very expensive medications with potentially serious side effects, as well as surgical

Precision medicine: Towards complexity science age.

PubMed

Yuan, Bing

2016-04-01

Precision medicine (PM) refers to the tailoring of the prevention and treatment strategies to the individual characteristics of each patient. Following the vigorous advocacy of the U.S. President Obama and China's President Xi, PM has now become a hot topic of common concern worldwide. PM does not merely refer to the skill set level but rather a comprehensive medical methodology. Hence, there is PM that builds on the analytical methodology of Western medical system as well as PM that builds on Chinese medicine (CM). The differences between the two systems, fundamentally speaking, are the differences in methodology to describe the body constitution that based on reductionism and holism. Today, as science advances to complex systems, the mainstream analytical reductionism advances to the holistic synthesis era, it is imperative to introduce CM's holistic body constitution to the modern medical system in order to progress to PM. PM with its foundation on holistic body constitution, is a medical system that integrates Western medicine and CM, is the highest attainment of "PM" in the future.

The spectrum of medical errors: when patients sue

PubMed Central

Kels, Barry D; Grant-Kels, Jane M

2012-01-01

Inarguably medical errors constitute a serious, dangerous, and expensive problem for the twenty-first-century US health care system. This review examines the incidence, nature, and complexity of alleged medical negligence and medical malpractice. The authors hope this will constitute a road map to medical providers so that they can better understand the present climate and hopefully avoid the “Scylla and Charybdis” of medical errors and medical malpractice. Despite some documented success in reducing medical errors, adverse events and medical errors continue to represent an indelible stain upon the practice, reputation, and success of the US health care industry. In that regard, what may be required to successfully attack the unacceptably high severity and volume of medical errors is a locally directed and organized initiative sponsored by individual health care organizations that is coordinated, supported, and guided by state and federal governmental and nongovernmental agencies. PMID:22924008

A novel drug management system in the Febuxostat versus Allopurinol Streamlined Trial: A description of a pharmacy system designed to supply medications directly to patients within a prospective multicenter randomised clinical trial.

PubMed

Rogers, Amy; Flynn, Robert Wv; McDonnell, Patrick; Mackenzie, Isla S; MacDonald, Thomas M

2016-12-01

Trials of investigational medicinal products are required to adhere to strict guidelines with regard to the handling and supply of medication. Information technology offers opportunities to approach clinical trial methodology in new ways. This report summarises a novel pharmacy system designed to supply trial medications directly to patients by post in the Febuxostat versus Allopurinol Streamlined Trial. A bespoke web-based software package was designed to facilitate the direct supply of trial medications to Febuxostat versus Allopurinol Streamlined Trial participants from a pharmacy based in the Medicines Monitoring Unit, University of Dundee. To date, 65,467 packs of medication have been dispensed using the system to 3978 patients. Up to 238 packs per day have been dispensed. The Medicines Monitoring Unit Febuxostat versus Allopurinol Streamlined Trial drug management system is an effective method of administering the complex drug supply requirements of a large-scale clinical trial with advantages over existing arrangements. A low rate of loss to follow-up in the Febuxostat versus Allopurinol Streamlined Trial may be attributable to the drug management system. © The Author(s) 2016.

Intestinal Rehabilitation Programs in the Management of Pediatric Intestinal Failure and Short Bowel Syndrome.

PubMed

Merritt, Russell J; Cohran, Valeria; Raphael, Bram P; Sentongo, Timothy; Volpert, Diana; Warner, Brad W; Goday, Praveen S

2017-11-01

Intestinal failure is a rare, debilitating condition that presents both acute and chronic medical management challenges. The condition is incompatible with life in the absence of the safe application of specialized and individualized medical therapy that includes surgery, medical equipment, nutritional products, and standard nursing care. Intestinal rehabilitation programs are best suited to provide such complex care with the goal of achieving enteral autonomy and oral feeding with or without intestinal transplantation. These programs almost all include pediatric surgeons, pediatric gastroenterologists, specialized nurses, and dietitians; many also include a variety of other medical and allied medical specialists. Intestinal rehabilitation programs provide integrated interdisciplinary care, more discussion of patient management by involved specialists, continuity of care through various treatment interventions, close follow-up of outpatients, improved patient and family education, earlier treatment of complications, and learning from the accumulated patient databases. Quality assurance and research collaboration among centers are also goals of many of these programs. The combined and coordinated talents and skills of multiple types of health care practitioners have the potential to ameliorate the impact of intestinal failure and improve health outcomes and quality of life.

Understanding practitioner professionalism in Aboriginal and Torres Strait Islander health: lessons from student and registrar placements at an urban Aboriginal and Torres Strait Islander primary healthcare service.

PubMed

Askew, Deborah A; Lyall, Vivian J; Ewen, Shaun C; Paul, David; Wheeler, Melissa

2017-10-01

Aboriginal and Torres Strait Islander peoples continue to be pathologised in medical curriculum, leaving graduates feeling unequipped to effectively work cross-culturally. These factors create barriers to culturally safe health care for Aboriginal and Torres Strait Islander peoples. In this pilot pre-post study, the learning experiences of seven medical students and four medical registrars undertaking clinical placements at an urban Aboriginal and Torres Strait Islander primary healthcare service in 2014 were followed. Through analysis and comparison of pre- and post-placement responses to a paper-based case study of a fictitious Aboriginal patient, four learning principles for medical professionalism were identified: student exposure to nuanced, complex and positive representations of Aboriginal peoples; positive practitioner role modelling; interpersonal skills that build trust and minimise patient-practitioner relational power imbalances; and knowledge, understanding and skills for providing patient-centred, holistic care. Though not exhaustive, these principles can increase the capacity of practitioners to foster culturally safe and optimal health care for Aboriginal peoples. Furthermore, competence and effectiveness in Aboriginal health care is an essential component of medical professionalism.

Implementation of behavioral health interventions in real world scenarios: Managing complex change.

PubMed

Clark, Khaya D; Miller, Benjamin F; Green, Larry A; de Gruy, Frank V; Davis, Melinda; Cohen, Deborah J

2017-03-01

A practice embarks on a radical reformulation of how care is designed and delivered when it decides to integrate medical and behavioral health care for its patients and success depends on managing complex change in a complex system. We examined the ways change is managed when integrating behavioral health and medical care. Observational cross-case comparative study of 19 primary care and community mental health practices. We collected mixed methods data through practice surveys, observation, and semistructured interviews. We analyzed data using a data-driven, emergent approach. The change management strategies that leadership employed to manage the changes of integrating behavioral health and medical care included: (a) advocating for a mission and vision focused on integrated care; (b) fostering collaboration, with a focus on population care and a team-based approaches; (c) attending to learning, which includes viewing the change process as continuous, and creating a culture that promoted reflection and continual improvement; (d) using data to manage change, and (e) developing approaches to finance integration. This paper reports the change management strategies employed by practice leaders making changes to integrate care, as observed by independent investigators. We offer an empirically based set of actionable recommendations that are relevant to a range of leaders (policymakers, medical directors) and practice members who wish to effectively manage the complex changes associated with integrated primary care. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Why are some evidence-based care recommendations in chronic obstructive pulmonary disease better implemented than others? Perspectives of medical practitioners

PubMed Central

Johnston, Kylie N; Young, Mary; Grimmer-Somers, Karen A; Antic, Ral; Frith, Peter A

2011-01-01

Background Clinical guidelines for management of patients with chronic obstructive pulmonary disease (COPD) include recommendations based on high levels of evidence, but gaps exist in their implementation. The aim of this study was to examine the perspectives of medical practitioners regarding implementation of six high-evidence recommendations for the management of people with COPD. Methods Semi-structured interviews were conducted with medical practitioners involved with care of COPD patients in hospital and general practice. Interviews sought medical practitioners’ experience regarding implementation of smoking cessation, influenza vaccination, pulmonary rehabilitation, guideline-based medications, long-term oxygen therapy for hypoxemia and plan and advice for future exacerbations. Interviews were audiotaped, transcribed verbatim and analyzed using content analysis. Results Nine hospital-based medical practitioners and seven general practitioners participated. Four major categories were identified which impacted on implementation of the target recommendations in the care of patients with COPD: (1) role clarity of the medical practitioner; (2) persuasive communication with the patient; (3) complexity of behavioral change required; (4) awareness and support available at multiple levels. For some recommendations, strength in all four categories provided significant enablers supporting implementation. However, with regard to pulmonary rehabilitation and plans and advice for future exacerbations, all identified categories that presented barriers to implementation. Conclusion This study of medical practitioner perspectives has indicated areas where significant barriers to the implementation of key evidence-based recommendations in COPD management persist. Developing strategies to target the identified categories provides an opportunity to achieve greater implementation of those high-evidence recommendations in the care of people with COPD. PMID:22259242

Aviation and the delivery of medical care in remote regions: the Lesotho HIV experience.

PubMed

Furin, Jennifer; Shutts, Mike; Keshavjee, Salmaan

2008-02-01

In many regions of the world plagued by high burdens of disease, there is difficulty in accessing basic medical care. This is often due to logistical constraints and a lack of infrastructure such as roads. Medical aviation can play a major role in addressing some of these crucial issues as it allows for the rapid transport of patients, personnel, and medications to remote-and sometimes otherwise inaccessible-areas. Lesotho is a mountainous nation of 2 million people that provides a good example of medical aviation as a cornerstone in the delivery of health care. The population has a reported HIV seroprevalence of 25%, and many patients live in rural areas that are inaccessible by road. Mission Aviation Fellowship has joined forces with a medical team from the nongovernmental organization Partners In Health in an effort to launch a comprehensive program to address HIV and related problems in rural Lesotho. This medical aviation partnership has allowed for the provision of HIV prevention and treatment services to thousands of people living in the mountains. This commentary describes how medical aviation has been crucial in developing models to address complex, serious health problems in remote settings.

Perceived medication use challenges and coping strategies among medical outpatients in Nigeria.

PubMed

Yusuff, Kazeem B

2013-02-01

The use of medicines is an action that involves a change in behaviour and it is a complex construct involving reciprocal interactions between social, environmental and cognitive factors. This is particularly true when a patient uses medicines for asymptomatic chronic conditions, requiring life-long use. To identify patient-perceived medication use challenges, determine the coping strategies used and investigate the relationship between patient-perceived challenges and self-initiation of coping strategies. A premier 900-bed tertiary/teaching hospital located in Ibadan, Nigeria. Ten pharmacists conducted cross-sectional medication use interviews for a random sample of 324 medical outpatients in 4 weeks (25th October-19th November 2006). Patient-perceived challenges with prescribed medications, self-initiated coping strategies used and relationship between patient-perceived challenges and self-initiation of coping strategies Eighty-one percent (324) of the random sample of 400 patients consented and completed the interview. Of these, 50.3 % were males while 49.7 % were females with mean age (SD) of 51.5 (17.6) and 52.1 (17.4) years respectively. The most frequent diagnoses were hypertension (53 %) and type-2 diabetes + hypertension (14.5 %). Two hundred and twenty-four patients reported one or more perceived challenges. Of these, 43.8 % were 65 years or older and about half reported at least 3 challenges. The majority (95.6 %) of patients who reported perceived challenges initiated one or more coping strategies without the knowledge of their physicians or pharmacists. Of 100 patients who did not report any perceived challenge, 43 % admitted initiating strategies to maintain perceived "cure" of their medical conditions. Self-initiation and use of coping strategies was far more likely among patients who reported perceived challenges (OR: 28.4, 95 % CI 26.1-30.5). The number of coping strategies reported appeared strongly related to the number of perceived challenges (r = 0.91, p < 0.001). Perceived challenges associated with the use of prescribed medications and self-initiation of coping strategies appeared considerable among medical outpatients at a major teaching hospital in Nigeria. The risk of unauthorised initiation and use of varieties of coping strategies without the knowledge of clinicians was very high among patients who reported at least one perceived challenge.

The effects of utilizing a near-patient e-learning tool on medical student learning.

PubMed

Selzer, Rob; Tallentire, Victoria R; Foley, Fiona

2015-01-01

This study aimed to develop a near-patient, e-learning tool and explore student views on how utilization of such a tool influenced their learning. Third year medical students from Monash University in Melbourne, Australia were invited to trial a novel, near-patient, e-learning tool in two separate pilots within the ward environment. All participating students were invited to contribute to focus groups which were audio-recorded, transcribed verbatim and thematically analyzed. Four focus groups were conducted with a total of 17 participants. The emerging themes revealed influences on the students' learning both prior to and during a clinical encounter, as well as following completion of an e-learning module. The unifying concept which linked all six themes and formed the central feature of the experience was patient-centered learning. This occurred through the acquisition of contextualized knowledge and the facilitation of workplace integration. Utilization of a near-patient e-learning tool influences medical student learning in a number of complex, inter-related ways. Clinical e-learning tools are poised to become more commonplace and provide many potential benefits to student learning. However, incorporation of technology into clinical encounters requires specific skills which should form an integral part of primary medical training.

Pharmacogenetics in the Development of Lipid Lowering Medications: Lomitapide & Mipomersen in Clinical Practice.

PubMed

Marbach, Jeffrey A; Thapa, Jhapat; Goldenberg, Edward; Duffy, Danielle

2015-08-01

The familial hypercholesterolemias (FH) are a group of undertreated genetically inherited disorders of lipid metabolism that lead to severely elevated cholesterol levels and early onset cardiovascular disease. Aggressive lifestyle modifications and lipid-lowering medications such as statins and bile acid sequestrants are the backbone of current treatment. Despite these interventions, homozygous FH (HoFH) patients are unable to reach LDL-C targets and remain at significantly increased risk of cardiovascular disease. Recently, two novel lipid-lowering medications, lomitapide and mipomersen, have been approved for the treatment of HoFH. We present two patients with HoFH who have been unable to reach target LDL-C goals on standard therapy. Patient A is a 41-year-old male and patient B is a 64-year-old female, both of whom have complex histories of multi-vessel coronary artery disease. In attempt to improve their LDL-C levels and lower their cardiovascular risk, lomitapide and mipomersen were initiated in patient A and B, respectively. Through inhibition of the microsomal triglyceride transfer protein, lomitapide prevents the formation of triglyceride rich lipoproteins. Mipomersen is an antisense oligonucleotide that inhibits the translation of apolipoprotein B-100. Both medications employ novel mechanisms developed through advances in pharmacogenetic technology and achieve unprecedented LDL-C reductions.

Renal autotransplantation--a possibility in the treatment of complex renal vascular diseases and ureteric injuries.

PubMed

Hau, Hans Michael; Bartels, Michael; Tautenhahn, Hans-Michael; Morgul, Mehmet Haluk; Fellmer, Peter; Ho-Thi, Phuc; Benckert, Christoph; Uhlmann, Dirk; Moche, Michael; Thelen, Armin; Schmelzle, Moritz; Jonas, Sven

2012-12-31

We report our contemporary experiences with renal autotransplantation in patients with complicated renal vascular diseases and/or complex ureteral injuries. Since its first performance, renal autotransplantation has been steadily improved and become a safe and effective procedure. Between 1998 and 2006, 6 renal autotransplantations in 6 patients were performed at the University Medical Center of Leipzig. After nephrectomy and renal perfusion ex vivo, the kidney was implanted standardized in the fossa iliaca. The vessels were anastomized to the iliac vessels, the ureter was reimplanted in an extravesical tunneled ureteroneocystostomy technique according to Lich-Gregoir. Demographic, clinical, and laboratory data of the patients were collected and analyzed for pre-, intra-, and postoperative period. Indications for renal autotransplantation were complex renovascular diseases in 2 patients (1 with fibromuscular dysplasia and 1 with Takayasu's arteritis) and in 4 patients with complex ureteral injuries. The median duration of follow-up was 9.7 years (range: 5.6-13.3). The laboratory values of our 6 patients showed improvements of creatinine, urea and blood pressure levels in comparison to the preoperative status at the end of follow-up period. The present study reports excellent results of renal autotransplantation in patients with renovascular disease or complex ureteric injuries. After a median follow-up of 9.7 years all 6 patients present with stable renal function as well as normal blood pressure values. Postoperative complications were observed with a rate comparable to other studies.

Integration of outpatient infectious diseases clinic pharmacy services and specialty pharmacy services for patients with HIV infection.

PubMed

Gilbert, Elise M; Gerzenshtein, Lana

2016-06-01

The integration of specialty pharmacy services and existing outpatient clinical pharmacy services within an infectious diseases (ID) clinic to optimize the care of patients with human immunodeficiency virus (HIV) infection is described. The management of HIV-infected patients is a highly specialized area of practice, often requiring use of complex medication regimens for reduction of HIV-associated morbidity and mortality prophylaxis and treatment of opportunistic infections, and prevention of HIV transmission. To maximize the effectiveness and safety of treatment with antiretroviral agents and associated pharmacotherapies, an interdisciplinary team is often involved in patient care. At Chicago-based Northwestern Medicine (NM), the outpatient ID clinic has long worked with an interdisciplinary care team including physicians, clinical pharmacists, nurses, and social workers to care for patients with HIV infection. In April 2014, specialty pharmacy services for patients with HIV infection were added to the NM ID clinic's care model to help maintain continuity of care and enhance patient follow-up. The care model includes well-defined roles for clinical pharmacists, pharmacy residents and students on rotation, and licensed pharmacy technicians. Specialty pharmacy services, including medication education, prescription fulfillment, assistance with medication access (e.g., navigation of financial assistance programs, completion of prior-authorization requests), and treatment monitoring, allow for closed-loop medication management of the HIV-infected patient population. Integration of specialty pharmacy services with the interdisciplinary care provided in the outpatient NM ID clinic has enhanced continuity of care for patients with HIV infection in terms of prescription filling, medication counseling, and adherence monitoring. Copyright © 2016 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Controlling health costs: physician responses to patient expectations for medical care.

PubMed

Sabbatini, Amber K; Tilburt, Jon C; Campbell, Eric G; Sheeler, Robert D; Egginton, Jason S; Goold, Susan D

2014-09-01

Physicians have dual responsibilities to make medical decisions that serve their patients' best interests but also utilize health care resources wisely. Their ability to practice cost-consciously is particularly challenged when faced with patient expectations or requests for medical services that may be unnecessary. To understand how physicians consider health care resources and the strategies they use to exercise cost-consciousness in response to patient expectations and requests for medical care. Exploratory, qualitative focus groups of practicing physicians were conducted. Participants were encouraged to discuss their perceptions of resource constraints, and experiences with redundant, unnecessary and marginally beneficial services, and were asked about patient requests or expectations for particular services. Sixty-two physicians representing a variety of specialties and practice types participated in nine focus groups in Michigan, Ohio, and Minnesota in 2012 MEASUREMENTS: Iterative thematic content analysis of focus group transcripts Physicians reported making trade-offs between a variety of financial and nonfinancial resources, considering not only the relative cost of medical decisions and alternative services, but the time and convenience of patients, their own time constraints, as well as the logistics of maintaining a successful practice. They described strategies and techniques to educate patients, build trust, or substitute less costly alternatives when appropriate, often adapting their management to the individual patient and clinical environment. Physicians often make nuanced trade-offs in clinical practice aimed at efficient resource use within a complex flow of clinical work and patient expectations. Understanding the challenges faced by physicians and the strategies they use to exercise cost-consciousness provides insight into policy measures that will address physician's roles in health care resource use.

When high pressure, system constraints, and a social justice mission collide: A socio-structural analysis of emergency department social work services.

PubMed

Moore, Megan; Cristofalo, Margaret; Dotolo, Danae; Torres, Nicole; Lahdya, Alexandra; Ho, Leyna; Vogel, Mia; Forrester, Mollie; Conley, Bonnie; Fouts, Susan

2017-04-01

The emergency department (ED) can be a critical intervention point for many patients with multifaceted needs. Social workers have long been part of interdisciplinary ED teams. This study aimed to contribute to the limited understanding of social worker-patient interactions and factors influencing social work services in this setting. This paper reports a qualitative content analysis of social work medical record notes (N = 1509) of services provided to trauma patients in an urban, public, level 1 trauma center and an in-depth analysis of semi-structured interviews with ED social workers (N = 10). Eight major social work roles were identified: investigator, gatekeeper, resource broker, care coordinator, problem solver, crisis manager, advocate, discharge planner. Analyses revealed a complex interplay between ED social work services and multi-layered contexts. Using a social-ecological framework, we identified the interactions between micro or individual level factors, mezzo or local system level factors and macro environmental and systemic factors that play a role in ED interactions and patient services. Macro-level contextual influences were socio-structural forces including socioeconomic barriers to health, social hierarchies that reflected power differentials between providers and patients, and distrust or bias. Mezzo-level forces were limited resources, lack of healthcare system coordination, a challenging hierarchy within the medical model and the pressure to discharge patients quickly. Micro-level factors included characteristics of patients and social workers, complexity of patient stressors, empathic strain, lack of closure and compassion. All of these forces were at play in patient-social worker interactions and impacted service provision. Social workers were at times able to successfully navigate these forces, yet at other times these challenges were insurmountable. A conceptual model of ED social work and the influences on the patient-social worker interactions was developed to assist in guiding innovative research and practice models to improve services and outcomes in the complex, fast-paced ED. Copyright © 2017 Elsevier Ltd. All rights reserved.

When high pressure, system constraints, and a social justice mission collide: a socio-structural analysis of emergency department social work services

PubMed Central

Cristofalo, Margaret; Dotolo, Danae; Torres, Nicole; Lahdya, Alexandra; Ho, Leyna; Vogel, Mia; Forrester, Mollie; Conley, Bonnie; Fouts, Susan

2017-01-01

The emergency department (ED) can be a critical intervention point for many patients with multifaceted needs. Social workers have long been part of interdisciplinary ED teams. This study aimed to contribute to the limited understanding of social worker-patient interactions and factors influencing social work services in this setting. This paper reports a qualitative content analysis of social work medical record notes (N=1,509) of services provided to trauma patients in an urban, public, level 1 trauma center and an in-depth analysis of semi-structured interviews with ED social workers (N=10). Eight major social work roles were identified: investigator, gatekeeper, resource broker, care coordinator, problem solver, crisis manager, advocate, discharge planner. Analyses revealed a complex interplay between ED social work services and multi-layered contexts. Using a social-ecological framework, we identified the interactions between micro or individual level factors, mezzo or local system level factors and macro environmental and systemic factors that play a role in ED interactions and patient services. Macro-level contextual influences were socio-structural forces including socioeconomic barriers to health, social hierarchies that reflected power differentials between providers and patients, and distrust or bias. Mezzo-level forces were limited resources, lack of healthcare system coordination, a challenging hierarchy within the medical model and the pressure to discharge patients quickly. Micro-level factors included characteristics of patients and social workers, complexity of patient stressors, empathic strain, lack of closure and compassion. All of these forces were at play in patient-social worker interactions and impacted service provision. Social workers were at times able to successfully navigate these forces, yet at other times these challenges were insurmountable. A conceptual model of ED social work and the influences on the patient-social worker interactions was developed to assist in guiding innovative research and practice models to improve services and outcomes in the complex, fast-paced ED. PMID:28214722

Ethical choice in the medical applications of information theory.

PubMed

Haig, Scott V

2010-10-01

Alongside advances in medical information technology (IT), there is mounting physician and patient dissatisfaction with present-day clinical practice. The effect of introducing increasingly complex medical IT on the ethical dimension of the clinical physician's primary task (identified as direct patient care) can be scrutinized through analysis of the EMR software platform. We therefore (1) identify IT changes burdensome to the clinician in performing patient care and which therefore lower quality of care; and (2) suggest methods for clinicians to maintain high quality patient care as IT demands increase. Elemental relationships from information theory and physical chemistry are applied to the profit-generating creation and flow of medical information between patients, physicians, administrators, suppliers, and insurers. Ethical implications for patient care and the doctor-patient relationship are drawn in the light of these relationships. WHERE ARE WE NOW?: Little has been accomplished, or even discussed, regarding limiting healthcare IT growth. Quality of patient care is expected to suffer unless physicians carefully scrutinize, refine and occasionally reject portions of the increasing healthcare IT burden being placed upon them. WHERE DO WE NEED TO GO?: Better medicine, simply understood as more effective prevention and treatment of musculoskeletal disease, is our professional goal. We need to establish mechanisms whereby we can limit, control or even reverse IT changes that hinder this goal. Clinicians must confront the negative impact many healthcare IT changes have on patient care. HOW DO WE GET THERE?: Suggestions for maintaining high standards of practice in the face of the new IT burden include: (1) Increasing IT time-awareness. Clinicians should examine actual time spent in clinical versus computer-based activity and implement changes if that ratio is too high. (2) Increasing IT goal awareness. (3) Examine the software creating a medical record to see how much of what it records is there for financial, as opposed to medical reasons. Is the software helping my patient or someone else's bottom line? Is it for talking to colleagues about sick people or to insurance companies?

Medication Errors in Vietnamese Hospitals: Prevalence, Potential Outcome and Associated Factors

PubMed Central

Nguyen, Huong-Thao; Nguyen, Tuan-Dung; van den Heuvel, Edwin R.; Haaijer-Ruskamp, Flora M.; Taxis, Katja

2015-01-01

Background Evidence from developed countries showed that medication errors are common and harmful. Little is known about medication errors in resource-restricted settings, including Vietnam. Objectives To determine the prevalence and potential clinical outcome of medication preparation and administration errors, and to identify factors associated with errors. Methods This was a prospective study conducted on six wards in two urban public hospitals in Vietnam. Data of preparation and administration errors of oral and intravenous medications was collected by direct observation, 12 hours per day on 7 consecutive days, on each ward. Multivariable logistic regression was applied to identify factors contributing to errors. Results In total, 2060 out of 5271 doses had at least one error. The error rate was 39.1% (95% confidence interval 37.8%- 40.4%). Experts judged potential clinical outcomes as minor, moderate, and severe in 72 (1.4%), 1806 (34.2%) and 182 (3.5%) doses. Factors associated with errors were drug characteristics (administration route, complexity of preparation, drug class; all p values < 0.001), and administration time (drug round, p = 0.023; day of the week, p = 0.024). Several interactions between these factors were also significant. Nurse experience was not significant. Higher error rates were observed for intravenous medications involving complex preparation procedures and for anti-infective drugs. Slightly lower medication error rates were observed during afternoon rounds compared to other rounds. Conclusions Potentially clinically relevant errors occurred in more than a third of all medications in this large study conducted in a resource-restricted setting. Educational interventions, focusing on intravenous medications with complex preparation procedure, particularly antibiotics, are likely to improve patient safety. PMID:26383873

What does it take to set goals for self-management in primary care? A qualitative study.

PubMed

Lenzen, Stephanie Anna; van Dongen, Jerôme Jean Jacques; Daniëls, Ramon; van Bokhoven, Marloes Amantia; van der Weijden, Trudy; Beurskens, Anna

2016-12-01

There is an increasing number of patients with a chronic illness demanding primary care services. This demands for effective self-management support, including collaborative goal setting. Despite the fact that primary care professionals seem to have difficulties implementing goal setting, little information is available about the factors influencing the complexity of this process in primary care. The aim of this study was to contribute to an understanding of the complexity of self-management goal setting in primary care by exploring experts' and primary care professionals' experiences with self-management goal setting and viewpoints regarding influencing factors. A descriptive qualitative research methodology was adopted. Two focus groups and three individual interviews were conducted (total participants n = 17). Thematic content analysis was used to analyse the data. The findings were categorized into four main themes with subordinated subthemes. The themes focus around the complexity of setting non-medical goals and around professionals' skills and attitudes to negotiate and decide about goals with patients. Furthermore, patients' skills and attitudes for goal setting and the integration of goal setting in the time available were formulated as themes. Setting self-management goals in primary care, especially in family medicine, might require a shift from a medical perspective to a biopsychosocial perspective, with an increasing role set aside for the professional to coach the patient in expressing his self-management goals and to take responsibility for these goals. © The Author 2016. Published by Oxford University Press.

The Challenge of Managing Psoriasis: Unmet Medical Needs and Stakeholder Perspectives

PubMed Central

Feldman, Steven R.; Goffe, Bernard; Rice, Gary; Mitchell, Matthew; Kaur, Mandeep; Robertson, Debbie; Sierka, Debra; Bourret, Jeffrey A.; Evans, Tamara S.; Gottlieb, Alice

2016-01-01

Background Psoriasis is a debilitating chronic inflammatory autoimmune disease affecting approximately 7.4 million adults in the United States. Plaque psoriasis is the most common form, affecting 80% to 90% of patients. Objectives To describe the impact and challenges that psoriasis presents for various stakeholders, and to provide nondermatologist healthcare decision makers with information to enhance their contributions to drug and pharmacy benefit design discussions. Discussion Psoriasis carries an increased risk for early mortality and an increased prevalence of comorbidities, including psoriatic arthritis, cardiovascular disease, and diabetes. It is also associated with anxiety, depression, and social isolation, and can negatively impact patients' relationships, productivity, and careers. The physical, psychologic, social, and economic impact of psoriasis, plus the associated stigma, result in cumulative impairment over a patient's lifetime. The current treatments for moderate-to-severe psoriasis include topical therapy, phototherapy, and systemic drugs (nonbiologic and biologic); however, patient satisfaction remains low, combination therapy and treatment switching are common, and many patients remain untreated or undertreated. Clinicians should consider the patient holistically, and should select treatment based on a range of factors, including disease severity (with physical and psychosocial manifestations), susceptibility to cumulative life-course impairment (considering personality, behavior, and cognition), comorbidities, concomitant medication, and patient preference. It is estimated that the total annual direct cost of treating psoriasis in the United States in 2015 exceeded $12.2 billion. Conclusion Psoriasis is a complex disease, and appropriate management is correspondingly complex. Newer psoriasis treatments provide improved efficacy and safety versus traditional treatments, but challenges remain in ensuring patients access to these medications. An improved understanding of the barriers to appropriate treatment is needed, as well as clear and accessible information for payers and clinicians on current treatment options, to ensure that decision makers can control costs while providing patients with optimal care. PMID:28465778

Prospective Analysis of Decision Making During Joint Cardiology Cardiothoracic Conference in Treatment of 107 Consecutive Children with Congenital Heart Disease.

PubMed

Duignan, Sophie; Ryan, Aedin; O'Keeffe, Dara; Kenny, Damien; McMahon, Colin J

2018-05-12

The complexity and potential biases involved in decision making have long been recognised and examined in both the aviation and business industries. More recently, the medical community have started to explore this concept and its particular importance in our field. Paediatric cardiology is a rapidly expanding field and for many of the conditions we treat, there is limited evidence available to support our decision-making. Variability exists within decision-making in paediatric cardiology and this may influence outcomes. There are no validated tools available to support and examine consistent decision-making for various treatment strategies in children with congenital heart disease in a multidisciplinary cardiology and cardiothoracic institution. Our primary objective was to analyse the complexity of decision-making for children with cardiac conditions in the context of our joint cardiology and cardiothoracic conference (JCC). Two paediatric cardiologists acted as investigators by observing the weekly joint cardiology-cardiothoracic surgery conference and prospectively evaluating the degree of complexity of decision-making in the management of 107 sequential children with congenital heart disease discussed. Additionally, the group consensus on the same patients was prospectively assessed to compare this to the independent observers. Of 107 consecutive children discussed at our JCC conference 32 (27%) went on to receive surgical intervention, 20 (17%) underwent catheterisation and 65 (56%) received medical treatment. There were 53 (50%) cases rated as simple by one senior observer, while 54 (50%) were rated as complex to some degree. There was high inter-observer agreement with a Krippendorff's alpha of ≥ 0.8 between 2 observers and between 2 observers and the group consensus as a whole for grading of the complexity of decision-making. Different decisions were occasionally made on patients with the same data set. Discussions revisiting the same patient, in complex cases, resulted in different management decisions being reached in this series. Anchoring of decision-making was witnessed in certain cases. Potential application of decision making algorithms is discussed in making decisions in paediatric cardiology patients. Decision-making in our institution's joint cardiology-cardiothoracic conference proved to be complex in approximately half of our patients. Inconsistency in decision-making for patients with the same diagnosis, and different decisions made for the same complex patient at different time points confounds the reliability of the decision-making process. These novel data highlight the absence of evidence-based medicine for many decisions, occasional lack of consistency and the impact of anchoring, heuristics and other biases in complex cases. Validated decision-making algorithms may assist in providing consistency to decision-making in this setting.

Dementia, Decision Making, and Capacity.

PubMed

Darby, R Ryan; Dickerson, Bradford C

After participating in this activity, learners should be better able to:• Assess the neuropsychological literature on decision making and the medical and legal assessment of capacity in patients with dementia• Identify the limitations of integrating findings from decision-making research into capacity assessments for patients with dementia ABSTRACT: Medical and legal professionals face the challenge of assessing capacity and competency to make medical, legal, and financial decisions in dementia patients with impaired decision making. While such assessments have classically focused on the capacity for complex reasoning and executive functions, research in decision making has revealed that motivational and metacognitive processes are also important. We first briefly review the neuropsychological literature on decision making and on the medical and legal assessment of capacity. Next, we discuss the limitations of integrating findings from decision-making research into capacity assessments, including the group-to-individual inference problem, the unclear role of neuroimaging in capacity assessments, and the lack of capacity measures that integrate important facets of decision making. Finally, we present several case examples where we attempt to demonstrate the potential benefits and important limitations of using decision-making research to aid in capacity determinations.

OCIS: 15 years' experience with patient-centered computing.

PubMed

Enterline, J P; Lenhard, R E; Blum, B I; Majidi, F M; Stuart, G J

1994-01-01

In the mid-1970s, the medical and administrative staff of the Oncology Center at Johns Hopkins Hospital recognized a need for a computer-based clinical decision-support system that organized patients' information according to the care continuum, rather than as a series of event-specific data. This is especially important in cancer patients, because of the long periods in which they receive complex medical treatment and the enormous amounts of data generated by extremely ill patients with multiple interrelated diseases. During development of the Oncology Clinical Information System (OCIS), it became apparent that administrative services, research systems, ancillary functions (such as drug and blood product ordering), and financial processes should be integrated with the basic patient-oriented database. With the structured approach used in applications development, new modules were added as the need for additional functions arose. The system has since been moved to a modern network environment with the capacity for client-server processing.

The direct costs of drug-induced skin reactions.

PubMed

Kiepurska, Nina; Paluchowska, Elwira; Owczarek, Witold; Szkultecka-Dębek, Monika; Jahnz-Różyk, Karina

2017-05-11

[b] Abstract Objective.[/b] The aim of the study was an assessment of direct costs of patients hospitalised for for skin adverse drug reactions during 2002-2012 in the Department of Dermatology at the Military Institute of Medicine (Ministry of Defence) in Warsaw. The analysis was carried out from the perspectives of the public payer and service provider. [b]Materials and method. [/b]The retrospective study was carried out in a group of 164 adult patients due to skin adverse drug reactions. Analysis was based on data from patient medical records and medical orders which provided information on the used resources, including diagnostic tests, medical consultations, medicinal products, hospitalisation duration, together with cost estimation, regardless of the treatment being the cause of the skin reaction. [b]Results[/b]. According to the International Statistical Classification of Diseases and Related Health Problems(ICD) diagnosis and scores, assigned by the National Healthcare Fund, it has been estimated that patient hospitalisation at the Department of Dermatology for skin drug reaction incurred costs at the average amount of €717.00 per patient. The complex diagnostics and pharmacotherapy of the same group of patients generated costs for the hospital at the average amount of €680 per patient. [b]Conclusions[/b]. As a result of the analysis, the therapy for skin adverse drug effects generates significant costs, both for the payer and the service provider. Since the costs are comparable, it seems that the pricing of medical procedures by the public payer is adequate for the costs incurred by the medical service provider.

Tricuspid Regurgitation – Medical Management and Evolving Interventional Concepts

PubMed Central

Beckhoff, Frederik; Alushi, Brunilda; Jung, Christian; Navarese, Eliano; Franz, Marcus; Kretzschmar, Daniel; Wernly, Bernhard; Lichtenauer, Michael; Lauten, Alexander

2018-01-01

Severe tricuspid regurgitation (TR) is a complex condition of the right ventricle (RV) and tricuspid valve apparatus and is frequently associated with symptomatic heart failure and a significant morbidity and mortality. In these patients, left heart pathologies lead to chronic pressure overload of the RV, eventually causing progressive RV dilatation and functional TR. Therefore, TR cannot be considered as isolated heart valve disease pathology but has to be understood and treated as one component of a complex structural RV pathology and is frequently also a marker of an advanced stage of cardiac disease. In these patients, medical therapy restricted to diuretics and heart failure medication is frequently ineffective. Also, severe TR in the setting of advanced heart failure constitutes a high risk for cardiac surgery. Neither one of these treatment options has demonstrated a beneficial effect on long-term prognosis. The recent innovations in transcatheter technology led to efforts to develop interventional approaches to severe TR. Multiple innovative treatment concepts are currently under preclinical and clinical investigation to replace or repair TV function. However, up to date none of these approaches is established and there is still a lack of clinical data to support the efficacy of transcatheter TR treatment. PMID:29892601

Application of the Beers Criteria to Alternate Level of Care Patients in Hospital Inpatient Units

PubMed Central

Slaney, Heather; MacAulay, Stacey; Irvine-Meek, Janice; Murray, Joshua

2015-01-01

Background: The Beers criteria were developed to help in identifying potentially inappropriate medications (PIMs) for elderly patients. These medications are often associated with adverse events and limited effectiveness in older adults. Patients awaiting an alternate level of care (ALC patients) are those who no longer require acute care hospital services and are waiting for placement elsewhere. They are often elderly, have complex medication regimens, and are at high risk of adverse events. At the time of this study no studies had applied the Beers criteria to ALC patients in Canadian hospitals. Objectives: To determine the proportion of ALC patients receiving PIMs and the proportion experiencing selected PIM-related adverse events. Methods: A retrospective chart review of ALC patients 65 years of age or older was performed to identify PIMs and the occurrence of selected adverse events (specifically central nervous system [CNS] events, falls, bradycardia, hypoglycemia, seizures, insomnia, gastrointestinal bleeding, and urinary tract infections). A logistic regression model with a random intercept for each patient was constructed to estimate odds ratios and probabilities of adverse events. Results: Fifty-two ALC patients were included in the study. Of these, 48 (92%) were taking a PIM. Of the 922 adverse events evaluated, 407 (44.1%) were associated with a regularly scheduled PIM. Among patients who were taking regularly scheduled PIMs, there was a significantly increased probability of an adverse CNS event and of a fall (p < 0.001 for both). The most common PIM medication classes were first-generation antihistamines (24 [46%] of the 52 patients), antipsychotics (21 patients [40%]), short-acting benzodiazepines (15 patients [29%]), and nonbenzodiazepine hypnotics (14 patients [27%]). Conclusions: A high proportion of ALC patients were taking PIMs and experienced an adverse event that may have been related to these drugs. These findings suggest that the ALC population might benefit from regular medication review and monitoring to prevent or detect adverse events. PMID:26157183

"Bending the cost curve" in gastroenterology.

PubMed

Slattery, E; Harewood, G C; Murray, F; Patchett, S

2013-12-01

Increasing attention is being focused on reigning in escalating costs of healthcare, i.e. trying to 'bend the cost curve'. In gastroenterology (GI), inpatient hospital care represents a major component of overall costs. This study aimed to characterize the trend in cost of care for GI-related hospitalizations in recent years and to identify the most costly diagnostic groups. All hospital inpatients admitted between January 2008 and December 2009 with a primary diagnosis of one of the six most common GI-related Diagnosis Related Groups (DRGs) in this hospital system were identified; all DRGs contained at least 40 patients during the study period. Patient Level Costing (PLC) was used to express the total cost of hospital care for each patient; PLC comprised a weighted daily bed cost plus cost of all medical services provided (e.g., radiology, pathology tests) calculated according to an activity-based costing approach; cost of medications were excluded. All costs were discounted to 2009 values. Mean length of stay (LOS) was also calculated for each DRG. Over 2 years, 470 patients were admitted with one of the six most common GI DRGs. Mean cost of care increased from 2008 to 2009 for all six DRGs with the steepest increases seen in 'GI hemorrhage (non-complex)' (31 % increase) and 'Cirrhosis/Alcoholic hepatitis (non-complex)' (45 % increase). No differences in readmission rates were observed over time. There was a strong correlation between year-to-year change in costs and change in mean LOS, r = 0.93. The cost of GI-related inpatient care appears to be increasing in recent years with the steepest increases observed in non-complex GI hemorrhage and non-complex Cirrhosis/Alcoholic hepatitis. Efforts to control the increasing costs should focus on these diagnostic categories.

Breast-axillary complex in HIV/AIDS patients.

PubMed

Eni, U E; Naaya, H U; Yawe, K D T; Lawan, M A; Bakari, A A

2010-01-01

HIV/AIDS have not only increased the health care burden especially in developing countries, it equally complicates the presentation of many diseases. Some well known disease entities now occur in fulminant complexities not previously described or known as such. The objective of this article is to report an unusual presentation of HIV/AIDS patients to the surgeon with Axillary and ipsilateral breast swelling. This is a report of three cases seen and managed by the authors. Three adult female patients presented with progressively increasing axillary and ipsilateral breast swellings. They also had associated fevers and weight loss. Their main concern had been development of breast cancer. One of the patients was a known retroviral positive on Highly Active Anti-Retroviral Therapy (HAART). Examination revealed axillary abscess and ipsilateral breast oedema in two cases. The patient on HAART had a hard breast-axillary mass complex. Biopsy (FNAB) revealed inflammatory cells and no malignancy in all three cases. HIV screening was positive in all cases. One of the patients had excision of breast-axillary mass complex, and the histology showed features of chronic inflammation, with no malignant cells. The other two had incision and drainage of their axillary abscess. This shows the ubiquitous presentation of HIV/AIDS in our environment and surgeons should be aware of the breast axillary complex in HIV/AIDS. Medical practitioners should be careful to obtain accurate diagnosis before embarking on treatment especially mutilating surgical procedures.

Office managers: nobody knows the trouble they see.

PubMed

Marrone, S

1995-09-01

Computers, code revisions, and patients' changing expectations have added responsibility and a new level of complexity to the job of medical office manager. How are you and your office manager coping? Some experienced managers relay their views of this rapidly changing field.

Communication and Noncompliance: An Axiomatic Framework.

ERIC Educational Resources Information Center

Powers, William G.; Gonzales, M. Christina

Patient noncompliance with medical advice is of major concern to physicians. Although many do not consider compliance their responsibility, research studies indicate that physicians can control many of the variables influencing compliance. Physicians' verbal and nonverbal communication habits that convey directiveness, coldness, complexity, and…

Why do family doctors prescribe potentially inappropriate medication to elderly patients?

PubMed

Voigt, Karen; Gottschall, Mandy; Köberlein-Neu, Juliane; Schübel, Jeannine; Quint, Nadine; Bergmann, Antje

2016-07-22

Based on changes in pharmacokinetics and -dynamics in elderly patients, there are potentially inappropriate medications (PIM) that should be avoided in patients aged ≥ 65 years. Current studies showed prescription rates of PIM between 22.5 and 28.4 % in the primary care setting. The evidence concerning reasons for PIM prescription by FPs is limited. This mixed method study consisted of three research parts: 1) semi-standardized content analysis of patients' records, 2) qualitative interviews with FPs using a) open questions and b) selected patient-specific case vignettes and 3) qualitative interviews with FPs' medical assistants. The integration of qualitative interviews was used to explain the quantitative results (triangulation design). PIM were identified according to the German PRISCUS list. Descriptive and multivariate statistical analysis was done using SPSS 22.0. Qualitative content analysis of interviews was used to classify the content of the interviews for indicating pertinent categories. All data were pseudonymously recorded and analyzed. Content analysis of 1846 patients' records and interviews with 7 related FPs were conducted. Elderly patients [n = 1241, mean age: 76, females: 56.6 %] were characterized in average by 8.3 documented chronic diagnosis. 23.9 % of elderly patients received at least one PIM prescription. Sedatives/hypnotics were the most frequent prescribed PIM-drugs (13.7 %). Mental disorders, gender and number of long-term medication were detected as predictors for the probability of a PIM prescription. Common reported reasons for PIM prescription by FPs concerned limited knowledge regarding PIM, limited applicability of PIM lists in daily practice, lack of time, having no alternatives in medication, stronger patient-related factors than age that influence prescription, own bad experiences regarding changes of medication or refusal of following prescriptions of sedative/hypnotics. It is essential to see FPs in a complex decision making situation with several influencing factors on their prescribing, including: patient-oriented prioritization, FPs' experiences in daily practice, FPs' knowledge regarding existing recommendations and their trust in it and organizational characteristics of FPs' daily medical practice. These pros and cons of PIM prescription in elderly patients should be considered in FPs' advanced training.

Minorities with lupus nephritis and medications: a study of facilitators to medication decision-making.

PubMed

Singh, Jasvinder A; Qu, Haiyan; Yazdany, Jinoos; Chatham, Winn; Shewchuk, Richard

2015-12-17

Medication decision-making poses a challenge for a significant proportion of patients. This is an even more challenging for patients who have complex, rare, immune conditions that affect them at a young age and are associated with the use of life-long treatment, perceived by some as having significant risk of side effects and toxicity. The aim of our study was to examine the perspectives of women with lupus nephritis on facilitators to medication decision-making. We used the nominal group technique (NGT), a structured formative process to elicit patient perspectives. An NGT expert moderated eight patient group meetings. Participants (n = 52) responded to the question "What sorts of things make it easier for people to decide to take the medicines that doctors prescribe for treating their lupus kidney disease?" Patients nominated, discussed, and prioritized facilitators to medication decisional processes. Fifty-two women with lupus nephritis participated in eight NGT meetings (27 African-American, 13 Hispanic, and 12 Caucasian). Average age was 40.6 years (standard deviation (SD) = 13.3), and disease duration was 11.8 years (SD = 8.3); 36.5 % obtained at least a college education, and 55.8 % had difficulty in reading health materials. Patients generated 280 decision-making facilitators (range of 26 to 42 per panel). Of these, 102 (36 %) facilitators were perceived by patients as having relatively more influence in decision-making processes than others. Prioritized facilitators included effective patient-physician communication regarding benefits/harms, patient desire to live a normal life and improve quality of life, concern for their dependents, experiencing benefits and few/infrequent/no harms with lupus medications, and their affordability. Relative to African-Americans, Caucasian and Hispanic patients endorsed a smaller percentage of facilitators as influential. Level of agreement with which patients within panels independently agreed in their selections of the three most influential facilitators ranged from 33 % to 60 %. We identified facilitators to lupus medication decision-making. This information will be used to populate a decision aid for lupus nephritis.

In the Right Place at the Right Time: Asian English Accents in a Listening Test for Healthcare Professions

ERIC Educational Resources Information Center

Suebsook, Khwanchanok; Adunyarittigun, Dumrong

2016-01-01

The rise of medical tourism and the increasing number of international patients from Asian countries have led Thai healthcare professionals to serve a lot of Asian patients and to encounter a complexity of language use in their workplace. There is a necessity for these professionals to strive for an understanding of Asian accents spoken by the…

Predictors of thirty-day readmission among hospitalized family medicine patients.

PubMed

Garrison, Gregory M; Mansukhani, Meghna P; Bohn, Bradley

2013-01-01

Hospital readmissions within 30 days of initial discharge occur frequently. In studies of elderly patients receiving Medicare, readmissions have been associated with poor-quality inpatient care, ineffective hospital-to-home transitions, patient characteristics, disease burden, and socioeconomic status. Among adult family medicine patients spanning a wide age range, we hypothesize that previous hospitalizations, length of stay, number of discharge medications, medical comorbidities, and patient demographics are associated with a greater risk of hospital readmission within 30 days. A retrospective case-control study of 276 family medicine inpatients was conducted to determine the factors associated with 30-day readmission. Bivariate statistics were computed and a multivariate analysis using logistic regression was performed to determine the independent effects of each factor. Patients readmitted within 30 days had more hospitalizations, more emergency department visits, longer hospital stays, more comorbidities, and more discharge medications and were less likely to be married. Multivariate logistic regression found that hospitalization within the previous 12 months (odds ratio, 2.71) and long hospital stays (odds ratio, 2.16) were associated with 30-day readmission; being married (odds ratio, 0.54) had a protective effect. This study demonstrates that factors previously found to be associated with 30-day readmission among elderly patients receiving Medicare also apply to family medicine patients of all ages. It also demonstrates prior hospitalizations, length of stay, and marital status are useful proxies for many more complicated factors, such as disease burden, medical complexity, and social issues, that influence hospital readmission.

A Novel Compound Analgesic Cream (Ketamine, Pentoxifylline, Clonidine, DMSO) for Complex Regional Pain Syndrome Patients.

PubMed

Russo, Marc A; Santarelli, Danielle M

2016-01-01

Evidence suggests that complex regional pain syndrome (CRPS) is a manifestation of microvascular dysfunction. Topical combinations of α2-adrenergic receptor agonists or nitric oxide donors with phosphodiesterase or phosphatidic acid inhibitors formulated to treat microvascular dysfunction have been shown to reduce allodynia in a rat model of CRPS-I. Driven by these findings, we assessed the outcomes of CRPS patients treated with a compound analgesic cream (CAC) consisting of ketamine 10%, pentoxifylline 6%, clonidine 0.2%, and dimethyl sulfoxide 6% to 10%. An audit was conducted on 13 CRPS patients who trialed the CAC. A detailed report was compiled for each patient which comprised baseline characteristics, including CRPS description, previous treatments, and pain scores (numerical pain rating scale; 0 to 10). Recorded outcomes consisted of pain scores, descriptive outcomes, and concurrent medications/treatments, for which basic analysis was performed to determine the effectiveness of the CAC. Case reports are presented for 3 patients with varying outcomes. Nine patients (69%) reported pain/symptom reduction (4.4 ± 2.1 vs. 6.3 ± 1.9) with use of the CAC. Six patients reported sustained benefits after 2 months of CAC use, and 2 patients reported complete resolution of pain/symptoms: one had early CRPS-I and the other received a partial CRPS diagnosis. An otherwise medication refractory and intolerant patient found partial benefit with the CAC. These results demonstrate promise for this topical combination as a useful treatment in multimodal therapy for patients with CRPS, with the potential to resolve pain/symptoms in early CRPS patients. © 2015 World Institute of Pain.

Using structured and unstructured data to identify patients' need for services that address the social determinants of health.

PubMed

Vest, Joshua R; Grannis, Shaun J; Haut, Dawn P; Halverson, Paul K; Menachemi, Nir

2017-11-01

Increasingly, health care providers are adopting population health management approaches that address the social determinants of health (SDH). However, effectively identifying patients needing services that address a SDH in primary care settings is challenging. The purpose of the current study is to explore how various data sources can identify adult primary care patients that are in need of services that address SDH. A cross-sectional study described patients in need of SDH services offered by a safety-net hospital's federally qualified health center clinics. SDH services of social work, behavioral health, nutrition counseling, respiratory therapy, financial planning, medical-legal partnership assistance, patient navigation, and pharmacist consultation were offered on a co-located basis and were identified using structured billing and scheduling data, and unstructured electronic health record data. We report the prevalence of the eight different SDH service needs and the patient characteristics associated with service need. Moreover, characteristics of patients with SDH services need documented in structured data sources were compared with those documented by unstructured data sources. More than half (53%) of patients needed SDH services. Those in need of such services tended to be female, older, more medically complex, and higher utilizers of services. Structured and unstructured data sources exhibited poor agreement on patient SDH services need. Patients with SDH services need documented by unstructured data tended to be more complex. The need for SDH services among a safety-net population is high. Identifying patients in need of such services requires multiple data sources with structured and unstructured data. Copyright © 2017. Published by Elsevier B.V.

Mail-order pharmacy experience of veterans living with AIDS/HIV.

PubMed

Desai, Karishma Rohanraj; Chewning, Betty; Wilcox, Andrew; Safdar, Nasia

2018-02-01

The VA system is the largest single provider of healthcare in the United States and to individuals infected with HIV specifically. High quality medication management is particularly important since HIV is a chronic infectious condition which requires taking multiple medications with strict requirements for adherence to medication regimens. Veterans Administration (VA) patients are required to obtain all chronic medications using the VA mail-order pharmacy system. Drawing on Donabedian's Quality Improvement framework, this study sought to examine experiences that Veterans with HIV have with the Veterans Administration medication mail-order system, and to explore opportunities for quality improvement. A sequential, explanatory mixed-methods design was used to interview Veterans receiving care at a Midwestern Veterans Administration Hospital using a mail-order experience survey followed by in-depth interviews. All 57 Veterans, out of 72, who were successfully contacted consented to participate. Overall, Veterans evaluated the mail-order service positively and valued the accuracy (correct medication delivery). However, a notable problem emerged with respect to assuring access to HIV medications with about half (47%) indicating running out of HIV medication. Respondents identified structural issues with respect to days covered by mailed medications (90 versus current 30 days) and process issues with scheduling new refills. Veterans also indicated the information sheets were too long, complex and not helpful for their queries. Patients were open to pharmacists playing an active role during clinic visits and felt this would help manage their conditions better. Veterans generally reported that the VA Mail-order service was of high quality. However, some findings indicate there are opportunities to improve this service to be more patient-centered particularly for vulnerable HIV patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Parent perspectives and preferences for strategies regarding nonsedated MRI scans in a pediatric oncology population.

PubMed

Walker, Breya; Conklin, Heather M; Anghelescu, Doralina L; Hall, Lacey P; Reddick, Wilburn E; Ogg, Robert; Jacola, Lisa M

2018-06-01

Children with cancer frequently require MRI scans for clinical purposes. Sedation with general anesthesia (GA) is often used to promote compliance, reduce motion, and alleviate anxiety. The use of GA for MRI scans is costly in terms of time, personnel, and medications. In addition, prominent risks are associated with anesthesia exposure in patients with complex medical conditions. Successful behavioral interventions have been implemented in clinical research settings to promote scan success and compliance. To our knowledge, parent/caregiver acceptability of behavioral interventions to promote nonsedated MRI has not been systematically investigated in a medically complex population. As a first step toward developing a protocol-based intervention to promote nonsedated scanning, we conducted a survey to explore parental perspectives regarding acceptability of nonsedated scanning and to gain information regarding preference for specific behavioral interventions to facilitate nonsedated MRI exams. Parents or guardians of 101 patients diagnosed with childhood cancer participated in a semi-structured survey via telephone. The sample was stratified by age group (8-12 years; 13-18 years), gender, and diagnosis (solid tumor (ST), brain tumor (BT), and acute lymphoblastic leukemia (ALL)). The majority of parents indicated that nonsedated MRI scans would be acceptable. Reduced anesthesia exposure was the most frequently identified benefit, followed by decreased irritability post-MRI scan, and shorter appointment time. Challenges included fear of movement and noise during scans and change in routine, with parents of younger children and those with a history of sedated exams identifying more challenges. Behavioral intervention preference differed by patient age and gender; however, education was ranked as most preferred overall. Parents of children treated for cancer consider behavior interventions to promote nonsedated scanning as acceptable. Patient characteristics should be considered when tailoring behavioral interventions. Results can inform future studies of behavioral interventions to promote nonsedated MRI scans. Future research should also investigate the risks associated with failed exams, both in terms of patient medical care and cost effectiveness.

The culture contributing to interruptions in the nursing work environment: An ethnography.

PubMed

Hopkinson, Susan G; Wiegand, Debra L

2017-12-01

To understand the occurrence of interruptions within the culture of the medical nursing unit work environment. Interruptions may lead to errors in nursing work. Little is known about how the culture of the nursing work environment contributes to interruptions. A micro-focused ethnographic study was conducted. Data collection involved extensive observation of a nursing unit, 1:1 observations of nurses and follow-up interviews with the nurses. Data were analysed from unstructured field notes and interview transcripts. The definitions of interruption and culture guided coding, categorising and identification of themes. A framework was developed that describes the medical nursing unit as a complex culture full of unpredictable, nonlinear changes that affect the entire interconnected system, often in the form of an interruption. The cultural elements contributing to interruptions included (i) the value placed on excellence in patient care and meeting personal needs, (ii) the beliefs that the nurses had to do everything by themselves and that every phone call was important, (iii) the patterns of changing patients, patient transport and coordination of resources and (iv) the normative practices of communicating and adapting. Interruptions are an integral part of the culture of a medical nursing unit. Uniformly decreasing interruptions may disrupt current practices, such as communication to coordinate care, that are central to nursing work. In future research, the nursing work environment must be looked at through the lens of a complex system. Interventions to minimise the negative impact of interruptions must take into account the culture of the nursing as a complex adaptive system. Nurses should be educated on their own contribution to interruptions and issues addressed at a system level, rather than isolating the interruption as the central issue. © 2017 John Wiley & Sons Ltd.

Assessing the Readability of Medical Documents: A Ranking Approach.

PubMed

Zheng, Jiaping; Yu, Hong

2018-03-23

The use of electronic health record (EHR) systems with patient engagement capabilities, including viewing, downloading, and transmitting health information, has recently grown tremendously. However, using these resources to engage patients in managing their own health remains challenging due to the complex and technical nature of the EHR narratives. Our objective was to develop a machine learning-based system to assess readability levels of complex documents such as EHR notes. We collected difficulty ratings of EHR notes and Wikipedia articles using crowdsourcing from 90 readers. We built a supervised model to assess readability based on relative orders of text difficulty using both surface text features and word embeddings. We evaluated system performance using the Kendall coefficient of concordance against human ratings. Our system achieved significantly higher concordance (.734) with human annotators than did a baseline using the Flesch-Kincaid Grade Level, a widely adopted readability formula (.531). The improvement was also consistent across different disease topics. This method's concordance with an individual human user's ratings was also higher than the concordance between different human annotators (.658). We explored methods to automatically assess the readability levels of clinical narratives. Our ranking-based system using simple textual features and easy-to-learn word embeddings outperformed a widely used readability formula. Our ranking-based method can predict relative difficulties of medical documents. It is not constrained to a predefined set of readability levels, a common design in many machine learning-based systems. Furthermore, the feature set does not rely on complex processing of the documents. One potential application of our readability ranking is personalization, allowing patients to better accommodate their own background knowledge. ©Jiaping Zheng, Hong Yu. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 23.03.2018.

Simplistic and complex thought in medicine: the rationale for a person-centered care model as a medical revolution

PubMed Central

Reach, Gérard

2016-01-01

According to the concept developed by Thomas Kuhn, a scientific revolution occurs when scientists encounter a crisis due to the observation of anomalies that cannot be explained by the generally accepted paradigm within which scientific progress has thereto been made: a scientific revolution can therefore be described as a change in paradigm aimed at solving a crisis. Described herein is an application of this concept to the medical realm, starting from the reflection that during the past decades, the medical community has encountered two anomalies that, by their frequency and consequences, represent a crisis in the system, as they deeply jeopardize the efficiency of care: nonadherence of patients who do not follow the prescriptions of their doctors, and clinical inertia of doctors who do not comply with good practice guidelines. It is proposed that these phenomena are caused by a contrast between, on the one hand, the complex thought of patients and doctors that sometimes escapes rationalization, and on the other hand, the simplification imposed by the current paradigm of medicine dominated by the technical rationality of evidence-based medicine. It is suggested therefore that this crisis must provoke a change in paradigm, inventing a new model of care defined by an ability to take again into account, on an individual basis, the complex thought of patients and doctors. If this overall analysis is correct, such a person-centered care model should represent a solution to the two problems of patients’ nonadherence and doctors’ clinical inertia, as it tackles their cause. These considerations may have important implications for the teaching and the practice of medicine. PMID:27103790

Ontology modularization to improve semantic medical image annotation.

PubMed

Wennerberg, Pinar; Schulz, Klaus; Buitelaar, Paul

2011-02-01

Searching for medical images and patient reports is a significant challenge in a clinical setting. The contents of such documents are often not described in sufficient detail thus making it difficult to utilize the inherent wealth of information contained within them. Semantic image annotation addresses this problem by describing the contents of images and reports using medical ontologies. Medical images and patient reports are then linked to each other through common annotations. Subsequently, search algorithms can more effectively find related sets of documents on the basis of these semantic descriptions. A prerequisite to realizing such a semantic search engine is that the data contained within should have been previously annotated with concepts from medical ontologies. One major challenge in this regard is the size and complexity of medical ontologies as annotation sources. Manual annotation is particularly time consuming labor intensive in a clinical environment. In this article we propose an approach to reducing the size of clinical ontologies for more efficient manual image and text annotation. More precisely, our goal is to identify smaller fragments of a large anatomy ontology that are relevant for annotating medical images from patients suffering from lymphoma. Our work is in the area of ontology modularization, which is a recent and active field of research. We describe our approach, methods and data set in detail and we discuss our results. Copyright © 2010 Elsevier Inc. All rights reserved.

'Looking as little like patients as persons well could': hypnotism, medicine and the problem of the suggestible subject in late nineteenth-century Britain.

PubMed

Chettiar, Teri

2012-07-01

During the late nineteenth century, many British physicians rigorously experimented with hypnosis as a therapeutic practice. Despite mounting evidence attesting to its wide-ranging therapeutic uses publicised in the 1880s and 1890s, medical hypnosis remained highly controversial. After a decade and a half of extensive medical discussion and debate surrounding the adoption of hypnosis by mainstream medical professionals--including a thorough inquiry organised by the British Medical Association--it was decisively excluded from serious medical consideration by 1900. This essay examines the complex question of why hypnosis was excluded from professional medical practice by the end of the nineteenth century. Objections to its medical adoption rarely took issue with its supposed effectiveness in producing genuine therapeutic and anaesthetic results. Instead, critics' objections were centred upon a host of social and moral concerns regarding the patient's state of suggestibility and weakened 'will-power' while under the physician's hypnotic 'spell'. The problematic question of precisely how far hypnotic 'rapport' and suggestibility might depart from the Victorian liberal ideal of rational individual autonomy lay at the heart of these concerns. As this essay demonstrates, the hypnotism debate was characterised by a tension between physicians' attempts to balance their commitment to restore patients to health and pervasive middle-class concerns about the rapid and ongoing changes transforming British society at the turn of the century.

Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making.

PubMed

Burkle, Christopher M; Mueller, Paul S; Swetz, Keith M; Hook, C Christopher; Keegan, Mark T

2012-11-21

Following passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians' decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients' ability to comprehend complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored. Attendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents' perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test. Three hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient's AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to "pass away in peace." Few (17%) would forgo an AD following a family's request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician's decision as to whether to comply with a patient's AD. Our findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient's initial wishes and preferences expressed by the AD.

Supervised Extraction of Diagnosis Codes from EMRs: Role of Feature Selection, Data Selection, and Probabilistic Thresholding.

PubMed

Rios, Anthony; Kavuluru, Ramakanth

2013-09-01

Extracting diagnosis codes from medical records is a complex task carried out by trained coders by reading all the documents associated with a patient's visit. With the popularity of electronic medical records (EMRs), computational approaches to code extraction have been proposed in the recent years. Machine learning approaches to multi-label text classification provide an important methodology in this task given each EMR can be associated with multiple codes. In this paper, we study the the role of feature selection, training data selection, and probabilistic threshold optimization in improving different multi-label classification approaches. We conduct experiments based on two different datasets: a recent gold standard dataset used for this task and a second larger and more complex EMR dataset we curated from the University of Kentucky Medical Center. While conventional approaches achieve results comparable to the state-of-the-art on the gold standard dataset, on our complex in-house dataset, we show that feature selection, training data selection, and probabilistic thresholding provide significant gains in performance.

Three-dimensional-printed cardiac prototypes aid surgical decision-making and preoperative planning in selected cases of complex congenital heart diseases: Early experience and proof of concept in a resource-limited environment.

PubMed

Kappanayil, Mahesh; Koneti, Nageshwara Rao; Kannan, Rajesh R; Kottayil, Brijesh P; Kumar, Krishna

2017-01-01

Three-dimensional. (3D) printing is an innovative manufacturing process that allows computer-assisted conversion of 3D imaging data into physical "printouts" Healthcare applications are currently in evolution. The objective of this study was to explore the feasibility and impact of using patient-specific 3D-printed cardiac prototypes derived from high-resolution medical imaging data (cardiac magnetic resonance imaging/computed tomography [MRI/CT]) on surgical decision-making and preoperative planning in selected cases of complex congenital heart diseases (CHDs). Five patients with complex CHD with previously unresolved management decisions were chosen. These included two patients with complex double-outlet right ventricle, two patients with criss-cross atrioventricular connections, and one patient with congenitally corrected transposition of great arteries with pulmonary atresia. Cardiac MRI was done for all patients, cardiac CT for one; specific surgical challenges were identified. Volumetric data were used to generate patient-specific 3D models. All cases were reviewed along with their 3D models, and the impact on surgical decision-making and preoperative planning was assessed. Accurate life-sized 3D cardiac prototypes were successfully created for all patients. The models enabled radically improved 3D understanding of anatomy, identification of specific technical challenges, and precise surgical planning. Augmentation of existing clinical and imaging data by 3D prototypes allowed successful execution of complex surgeries for all five patients, in accordance with the preoperative planning. 3D-printed cardiac prototypes can radically assist decision-making, planning, and safe execution of complex congenital heart surgery by improving understanding of 3D anatomy and allowing anticipation of technical challenges.

Understanding Spatially Complex Segmental and Branch Anatomy Using 3D Printing: Liver, Lung, Prostate, Coronary Arteries, and Circle of Willis.

PubMed

Javan, Ramin; Herrin, Douglas; Tangestanipoor, Ardalan

2016-09-01

Three-dimensional (3D) manufacturing is shaping personalized medicine, in which radiologists can play a significant role, be it as consultants to surgeons for surgical planning or by creating powerful visual aids for communicating with patients, physicians, and trainees. This report illustrates the steps in development of custom 3D models that enhance the understanding of complex anatomy. We graphically designed 3D meshes or modified imported data from cross-sectional imaging to develop physical models targeted specifically for teaching complex segmental and branch anatomy. The 3D printing itself is easily accessible through online commercial services, and the models are made of polyamide or gypsum. Anatomic models of the liver, lungs, prostate, coronary arteries, and the Circle of Willis were created. These models have advantages that include customizable detail, relative low cost, full control of design focusing on subsegments, color-coding potential, and the utilization of cross-sectional imaging combined with graphic design. Radiologists have an opportunity to serve as leaders in medical education and clinical care with 3D printed models that provide beneficial interaction with patients, clinicians, and trainees across all specialties by proactively taking on the educator's role. Complex models can be developed to show normal anatomy or common pathology for medical educational purposes. There is a need for randomized trials, which radiologists can design, to demonstrate the utility and effectiveness of 3D printed models for teaching simple and complex anatomy, simulating interventions, measuring patient satisfaction, and improving clinical care. Copyright © 2016 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

[Learning from the experiences of an arbitration unit for medical liability questions].

PubMed

Scheppokat, K D

2005-03-01

While other countries', e.g. the United States', experience with alternative dispute resolution (ADR) in medical malpractice has been disappointing, German physicians have instituted extrajudicial claims resolution as an alternative to civil litigation: Established by the Arztekammern (corporate bodies of professional self-governance) in the mid-1970s, the Schlichtungsstellen (SchlSt--claims resolution panels) offer patients and doctors, on a voluntary basis, proceedings directed toward achieving a settlement. The number of cases submitted to these panels has been constantly growing since. In 90% of cases decided upon by the panel, civil litigation was avoided. Doctors can, as exemplified by the operation of the SchlSt, tackle difficult and complex problems and solve them--without being funded or directed by outside agencies. What can be learnt from being, as a physician member, associated with a SchlSt for several years? (1) Physicians--as Eddy has pointed out--must make decisions about complex problems under difficult conditions on the basis of inadequate information. Expert testimony suffers from similar uncertainties. Decisions on individual cases cannot be improved by external and necessarily generalized ruling (disease management programs, other directives). (2) Errors and adverse events in medical care have to be accepted as principally unavoidable. Most claims heard by the panel have to do with operations and--in the non-surgical specialties--with invasive procedures. Medical tasks of high complexity, as many operative and invasive procedures indeed are, seem to have an inherent accident-proneness. Therefore decisions as to operations and invasive procedures should be weighed with utmost care. More is not always better (3) 25% of the patients filing claims with the SchlSt complain of deficient doctor-patient-communication. Failure of doctors and staff to communicate adequately with the patients and with their professional contacts plays an important role as risk factor for negligence and injury and even as cause of disputes and claims. (4) The GP, the generalist in a profession characterized by specialization, has to treat a wide spectrum of diseases, wider than any specialist. As far as can be seen, he does his job well. He needs adequate--if possible personal--contact with and support by his colleagues involved in the treatment of the same patient.

Construct Validity and Responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales and Infant Scales in the PICU.

PubMed

Aspesberro, François; Fesinmeyer, Megan D; Zhou, Chuan; Zimmerman, Jerry J; Mangione-Smith, Rita

2016-06-01

To assess the construct validity and the responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales and Infant Scales in the medical-surgical (PICU) and cardiac PICU. Prospective cohort study of 367 inpatients admitted either to the PICU or the cardiac ICU at Seattle Children's Hospital from January 2012 to June 2013. Parent/caregiver and child (≥ 8 yr old, developmentally appropriate, and critical illness resolved) Pediatric Quality of Life Inventory scores were obtained within 24 hours of PICU/cardiac ICU discharge and subsequently at 4-12 weeks following hospital discharge. Of the 491 eligible participants invited to participate, 367 (74.7% response rate) completed the Pediatric Quality of Life Inventory survey at ICU discharge, and of these, 263 (71.7% follow-up response rate) completed the follow-up survey 4-12 weeks after hospital discharge. Responsiveness was assessed by calculating improvement scores (difference between follow-up and ICU discharge scores, Δ Pediatric Quality of Life Inventory). Construct validity was examined by comparing mean improvement scores for known groups differing by medical complexity. At follow-up, [INCREMENT] Pediatric Quality of Life Inventory scores were as follows (mean ± SD): physical domain, 34.8 ± 32.0; and psychosocial domain, 23.1 ± 23.5. Patients with complex chronic or noncomplex chronic disease had physical functioning improvement scores that were 17.4 points (95% CI, -28.3 to -6.5; p < 0.001) and 19.5 points (95% CI, -30.4 to -8.5; p < 0.002) lower than children with no chronic illness, respectively. Patients with complex chronic disease exhibited psychosocial improvement scores that were 9.6 points (95% CI, -18.4 to -0.8; p < 0.033) lower than patients without chronic disease. Patients with noncomplex chronic disease had similar psychosocial improvement scores when compared with patients without chronic disease. As a measure of health-related quality of live, Pediatric Quality of Life Inventory demonstrated responsiveness and construct validity in a broad population of critically ill children. This measure represents a patient-centered clinically meaningful patient-or-parent-reported outcome measure for pediatric research assessing the clinical effectiveness of PICU/cardiac ICU interventions. When using health-related quality of life recovery as an outcome measure to assess clinical effectiveness in the PICU/cardiac ICU setting, measuring and controlling for the level of medical complexity is important in order to understand the true impact of clinical interventions.

Innovative interprofessional geriatric education for medical and nursing students: focus on transitions in care.

PubMed

Balogun, S A; Rose, K; Thomas, S; Owen, J; Brashers, V

2015-06-01

Interprofessional education (IPE) is crucial in fostering effective collaboration and optimal team-based patient care, all of which improve patient care and outcomes. Appropriate interprofessional communication is especially important in geriatrics where patients are vulnerable to adverse effects across the care continuum. Transitions in geriatric care are complex, involving several disciplines and requiring careful coordination. As part of the University of Virginia's initiative on IPE, we developed and implemented an interprofessional geriatric education workshop for nursing and medical students with a focus on transitions in care. A total of 254 students (144 medical students, 107 nursing students and 3 unknown) participated in a 90-min interactive, case-based workshop. Nursing and medical faculty facilitated the monthly workshops with small groups of medical and nursing students over 1 year. Self-perceived competencies in IPE skills and attitudes toward interprofessional teamwork were measured through post-workshop surveys. Data were analyzed using descriptive and nonparametric statistics, excluding the three unknown students. Over 90% of students were better able to describe the necessary interprofessional communication needed to develop a patient-centered care plan in transitioning patients between clinical sites. Four out of five students reported an enhanced appreciation of interprofessional teamwork. They were also able to identify legal, financial and social implications in transitions of care (75%). Nursing students consistently rated the workshop more highly than medical students across most domains (P < 0.05). Students improved and demonstrated their knowledge of interprofessional communication and teamwork skills required in transitions of geriatric care. Introducing these concepts in medical and nursing training may help in fostering effective interprofessional communication and collaboration. © The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Surgical scheduling categorization system (SSCS): A novel classification system to improve coordination and scheduling of operative cases in a tertiary pediatric medical system.

PubMed

Gantwerker, Eric A; Bannos, Cassandra; Cunningham, Michael J; Rahbar, Reza

2017-01-01

To describe a surgical categorization system to create a universal nomenclature, delineating patient complexity as a first step toward developing a true risk stratification system. Retrospective database review of all otolaryngology surgical procedures performed in a tertiary pediatric hospital system over one academic year (July 2012-June 2013). All otolaryngology surgical procedures were reviewed, encompassing 8478 procedures on 5711 patients. The attending otolaryngologist assigned surgical scheduling category (SSCS) at the time of case booking based on an institution specific guidelines. The guidelines are as follow: Category I was assigned to American Society of Anesthesiologists physical status classification (ASA) I/II patients, designating them appropriate for institution's suburban ambulatory surgery centers; Category II was ASA I/II patients with social or transportation issues; Category III was ASA I/II patients who required case coordination with other medical or surgical departments; Category IV was reserved for patients of any ASA class whom the surgeon designated to be of a higher complexity. 8478 total procedures analyzed with 7198 having complete records. 48% were Category I, 13.6% were Category II, 1.9% were Category III and 36.5% were Category IV. The ASA were 34.7% ASA I, 50% ASA II, 13.39% ASA III, and 1.9% ASA IV. Although the largest proportion of patients were ASA II (50%), 39.6% of all ASA II were Category IV. Category IV was split into 54.2% ASA II and 34% ASA III and shows that peri-operative surgical concerns were not encompassed by the ASA system. This surgical categorization system streamlines surgical scheduling in a tertiary pediatric hospital system, particularly with respect to the designation of cases as ambulatory surgery center or main operating room appropriate. The case mix complexity is also readily apparent, enhancing recognition of the coordination and attention required for the perioperative management of high complexity patients. The SSCS helps convey concerns not addressed by ASA physical status alone. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[The quantum gravitational therapy of myocarditis].

PubMed

Ovcharova, A P

1999-01-01

Complex therapy of myocarditis of rheumatic and non-rheumatic genesis using intravascular laser irradiation of blood, quercitrol, and enterosgel has an antiinflammatory, antioxidant action, improves myocardial contractility, is endowed with an antiaggregatory activity. The above therapeutic complex permits the reduction of the non-steroid antiinflammatory drugs intake as well as of the average time of hospital treatment by 2 to 3 days, it also makes for an earlier medical and social rehabilitation of patients.

Development of a simulated smart pump interface.

PubMed

Elias, Beth L; Moss, Jacqueline A; Shih, Alan; Dillavou, Marcus

2014-01-01

Medical device user interfaces are increasingly complex, resulting in a need for evaluation in clinicallyaccurate settings. Simulation of these interfaces can allow for evaluation, training, and use for research without the risk of harming patients and with a significant cost reduction over using the actual medical devices. This pilot project was phase 1 of a study to define and evaluate a methodology for development of simulated medical device interface technology to be used for education, device development, and research. Digital video and audio recordings of interface interactions were analyzed to develop a model of a smart intravenous medication infusion pump user interface. This model was used to program a high-fidelity simulated smart intravenous medication infusion pump user interface on an inexpensive netbook platform.

@neurIST: infrastructure for advanced disease management through integration of heterogeneous data, computing, and complex processing services.

PubMed

Benkner, Siegfried; Arbona, Antonio; Berti, Guntram; Chiarini, Alessandro; Dunlop, Robert; Engelbrecht, Gerhard; Frangi, Alejandro F; Friedrich, Christoph M; Hanser, Susanne; Hasselmeyer, Peer; Hose, Rod D; Iavindrasana, Jimison; Köhler, Martin; Iacono, Luigi Lo; Lonsdale, Guy; Meyer, Rodolphe; Moore, Bob; Rajasekaran, Hariharan; Summers, Paul E; Wöhrer, Alexander; Wood, Steven

2010-11-01

The increasing volume of data describing human disease processes and the growing complexity of understanding, managing, and sharing such data presents a huge challenge for clinicians and medical researchers. This paper presents the @neurIST system, which provides an infrastructure for biomedical research while aiding clinical care, by bringing together heterogeneous data and complex processing and computing services. Although @neurIST targets the investigation and treatment of cerebral aneurysms, the system's architecture is generic enough that it could be adapted to the treatment of other diseases. Innovations in @neurIST include confining the patient data pertaining to aneurysms inside a single environment that offers clinicians the tools to analyze and interpret patient data and make use of knowledge-based guidance in planning their treatment. Medical researchers gain access to a critical mass of aneurysm related data due to the system's ability to federate distributed information sources. A semantically mediated grid infrastructure ensures that both clinicians and researchers are able to seamlessly access and work on data that is distributed across multiple sites in a secure way in addition to providing computing resources on demand for performing computationally intensive simulations for treatment planning and research.

A BEME systematic review of UK undergraduate medical education in the general practice setting: BEME Guide No. 32.

PubMed

Park, Sophie; Khan, Nada F; Hampshire, Mandy; Knox, Richard; Malpass, Alice; Thomas, James; Anagnostelis, Betsy; Newman, Mark; Bower, Peter; Rosenthal, Joe; Murray, Elizabeth; Iliffe, Steve; Heneghan, Carl; Band, Amanda; Georgieva, Zoya

2015-05-06

General practice is increasingly used as a learning environment in undergraduate medical education in the UK. The aim of this project was to identify, summarise and synthesise research about undergraduate medical education in general practice in the UK. We systematically identified studies of undergraduate medical education within a general practice setting in the UK from 1990 onwards. All papers were summarised in a descriptive report and categorised into two in-depth syntheses: a quantitative and a qualitative in-depth review. 169 papers were identified, representing research from 26 UK medical schools. The in-depth review of quantitative papers (n = 7) showed that medical students learned clinical skills as well or better in general practice settings. Students receive more teaching, and clerk and examine more patients in the general practice setting than in hospital. Patient satisfaction and enablement are similar whether a student is present or not in a consultation, however, patients experience lower relational empathy. Two main thematic groups emerged from the qualitative in-depth review (n = 10): the interpersonal interactions within the teaching consultation and the socio-cultural spaces of learning which shape these interactions. The GP has a role as a broker of the interactions between patients and students. General practice is a socio-cultural and developmental learning space for students, who need to negotiate the competing cultures between hospital and general practice. Lastly, patients are transient members of the learning community, and their role requires careful facilitation. General practice is as good, if not better, than hospital delivery of teaching of clinical skills. Our meta-ethnography has produced rich understandings of the complex relationships shaping possibilities for student and patient active participation in learning.

[Pharmacological treatment conciliation methodology in patients with multiple conditions].

PubMed

Alfaro-Lara, Eva Rocío; Vega-Coca, María Dolores; Galván-Banqueri, Mercedes; Nieto-Martín, María Dolores; Pérez-Guerrero, Concepción; Santos-Ramos, Bernardo

2014-02-01

To carry out a bibliographic review in order to identify the different methodologies used along the reconciliation process of drug therapy applicable to polypathological patients. We performed a literature review. Data sources The bibliographic review (February 2012) included the following databases: Pubmed, EMBASE, CINAHL, PsycINFO and Spanish Medical Index (IME). The different methodologies, identified on those databases, to measure the conciliation process in polypathological patients, or otherwise elderly patients or polypharmacy, were studied. Study selection Two hundred and seventy three articles were retrieved, of which 25 were selected. Data extraction Specifically: the level of care, the sources of information, the use of registration forms, the established time, the medical professional in charge and the registered variables such as errors of reconciliation. Most of studies selected when the patient was admitted into the hospital and after the hospital discharge of the patient. The main sources of information to be highlighted are: the interview and the medical history of the patient. An established time is not explicitly stated on most of them, nor the registration form is used. The main professional in charge is the clinical pharmacologist. Apart from the home medication, the habits of self-medication and phytotherapy are also identified. The common errors of reconciliation vary from the omission of drugs to different forms of interaction with other medicinal products (drugs interactions). There is a large heterogeneity of methodologies used for reconciliation. There is not any work done on the specific figure of the polypathological patient, which precisely requires a standardized methodology due to its complexity and its susceptibility to errors of reconciliation. Copyright © 2012 Elsevier España, S.L. All rights reserved.