Drivers and strategies for avoiding overuse. A cross-sectional study to explore the experience of Spanish primary care providers handling uncertainty and patients requests

Objectives

Identify the sources of overuse from the point of view of the Spanish primary care professionals, and analyse the frequency of overuse due to pressure from patients in addition to the responses when professionals face these demands.

Design

A cross-sectional study.

Setting

Primary care in Spain.

Participants

A non-randomised sample of 2201 providers (general practitioners, paediatricians and nurses) was recruited during the survey.

Primary and secondary outcome measures

The frequency, causes and responsibility for overuse, the frequency that patients demand unnecessary tests or procedures, the profile of the most demanding patients, and arguments for dissuading the patient.

Results

In all, 936 general practitioners, 682 paediatricians and 286 nurses replied (response rate 18.6%). Patient requests (67%) and defensive medicine (40%) were the most cited causes of overuse. Five hundred and twenty-two (27%) received requests from their patients almost every day for unnecessary tests or procedures, and 132 (7%) recognised granting the requests. The lack of time in consultation, and information about new medical advances and treatments that patients could find on printed and digital media, contributed to the professional's inability to adequately counter this pressure by patients. Clinical safety (49.9%) and evidence (39.4%) were the arguments that dissuaded patients from their requests the most. Cost savings was not a convincing argument (6.8%), above all for paediatricians (4.3%). General practitioners resisted more pressure from their patients (x²=88.8, P<0.001, percentage difference (PD)=17.0), while nurses admitted to carrying out more unnecessary procedures (x²=175.7, P<0.001, PD=12.3).

Conclusion

Satisfying the patient and patient uncertainty about what should be done and defensive medicine practices explains some of the frequent causes of overuse. Safety arguments are useful to dissuade patients from their requests.

https://ift.tt/2LUp9Ze

Socioeconomic status and cigarette expenditure among US households: results from 2010 to 2015 Consumer Expenditure Survey

Objectives

To examine (1) the association between household socioeconomic status (SES) and whether a household spends money on cigarettes and (2) socioeconomic variations in proportion of total household expenditure spent on cigarettes among smoking households.

Methods

We pooled data from six consecutive years, 2010–2015, of the Consumer Expenditure Interview Survey. The interviews involved a structured questionnaire about household income, demographics and expenditures including expenditure on cigarettes. Households that reported cigarette expenditure in the previous 3 months were distinguished as smoking households. SES indicators were household poverty status, education and occupation of the head of household. Logistic regression was used to assess the association of household smoking status with SES. Fractional logistic regression was used to assess the association of cigarette expenditure as a proportion of total household expenditure with SES. The analysis sample size was 39 218.

Results

The probability of spending money on cigarettes was higher among lower SES households. Households in poverty compared with those above 300% of poverty threshold had 1.86 (95% CI 1.61 to 2.16), households headed by a person with less than high school education compared with those headed by a person with at least a bachelor's degree had 3.37 (95% CI 2.92 to 3.89) and households headed by a blue-collar work compared with those headed by a person in a managerial occupation had 1.45 (95% CI 1.26 to 1.66) higher odds of spending money on cigarettes. Similarly, the proportion of total household expenditure spent on cigarettes was higher among lower SES smoking households.

Conclusion

Lower SES households are more likely to spend money on cigarettes and spend a larger proportion of their total expenditure on cigarettes. We recommend strategies effective in reducing smoking among low SES smokers.

https://ift.tt/2t3J94L

What insights do patients and caregivers have on acute kidney injury and posthospitalisation care? A single-centre qualitative study from Toronto, Canada

Objectives

Hospitalisation with acute kidney injury (AKI) is associated with short-term and long-term adverse events, but patient and caregiver experiences with AKI are not well described. We sought to better understand patient and caregiver perspectives after a hospitalisation with AKI to inform discharge strategies that may improve outcomes for this high-risk population.

Design

Qualitative study with semistructured interviews.

Setting

Tertiary care hospital in Toronto, Ontario, Canada.

Participants

Adult patients (n=15) who survived a hospitalisation with Kidney Disease Improving Global Outcomes stage 2 or 3 AKI from May to December 2016. We also interviewed five patient caregivers. We required patients to have no previous evidence of severe chronic kidney disease (ie, prior receipt of dialysis, previous kidney transplantation or pre-existing estimated glomerular filtration rate (eGFR) under 30 mL/min/1.73 m²).

Results

We identified three over-arching themes: (1) prioritisation of conditions other than AKI, reflected by the importance placed on other comorbidities and the omission of AKI as part of the ongoing medical history; (2) variability in comprehension of the significance of AKI, represented by minimal knowledge of the causes and symptoms associated with AKI, along with misinformation on the kidneys' ability to self-repair; and (3) anxiety from discharge planning and competing health demands, illustrated by complicated discharge plans involving multiple specialist appointments.

Conclusions

Patients and caregivers view AKI as a short-term and reversible condition, giving it little thought during the postdischarge period. As a result, reliance on patients and caregivers to report an episode of AKI to their outpatient physicians is unlikely to be successful. Patient-centred tools and decision aids are needed to bridge the gap between a hospitalisation with AKI and the safe transition to the outpatient setting.

https://ift.tt/2LSvQem

Changes in the rate of publicly financed knee arthroscopies: an analysis of data from the Norwegian patient registry from 2012 to 2016

Objective

To examine rates of publicly financed knee arthroscopic surgery in Norway between 2012 and 2016.

Design

Analysis of anonymised data from the National Patient Registry.

Interventions

Beginning in 2012, South-Eastern Norway Regional Health Authority implemented administrative measures to bring down rates of knee arthroscopy. Similar measures were not introduced in the other three Regional Health Authorities.

Main outcome measures

We analysed annual national rates of publicly financed knee arthroscopies in 2012 and 2016. We compared the rates in South-Eastern Norway Regional Health Authority with corresponding rates in the rest of the country. Variations by county, public hospital versus publicly reimbursed private hospital, gender and age were also assessed.

Results

The overall annual rate of arthroscopic procedures declined by 33% from 2012 to 2016, from 310 to 207 per 100 000 inhabitants, respectively. Hospitals in South-Eastern Norway Regional Health Authority reported a 48% reduction, compared with mean 13% in the other three Regional Health Authorities. In public hospitals, rates decreased nationally by 42%, while rates in publicly reimbursed private hospitals increased by 12%. Rates in publicly reimbursed private hospitals decreased by 30% in South-Eastern Norway Regional Health Authority but increased by 63% in the other Regional Health Authorities. The proportion of patients ≥50 years (excluding meniscal repairs) in Norway was 54% in 2012 and fell to 46% in 2016. Average rates per county varied by a factor of 3:1.

Conclusion

We report a marked overall reduction of knee arthroscopic procedures from 2012 to 2016 in publicly funded hospitals. The largest decrease was reported in South-Eastern Norway Regional Health Authority, and this coincides in time with implemented administrative measures. The results suggest that the trend of increasing rates of knee arthroscopies can be reversed through purposeful professional and administrative interventions.

https://ift.tt/2JJgtZ0

An international qualitative study exploring patients experiences of cutaneous leishmaniasis: study set-up and protocol

Introduction

Lack of investments in drug development, lack of standardisation of clinical trials and the complexity of disease presentations contribute to the current lack of effective, safe and adapted treatments for cutaneous leishmaniasis (CL). One aspect concerns outcomes affecting patients' quality of life (QoL): these are hardly assessed in trials, despite potential functional and/or aesthetic impairment caused by CL, which typically affects disadvantaged and vulnerable people living in rural areas. Here, we describe the approach used to bring perspectives of patients with CL into designing and assessing treatments.

Methods and analysis

This international qualitative study uses interviews with patients to explore their experiences with CL to (1) elicit outcomes and eligibility criteria for clinical trials important to them and (2) to better understand their needs and views about the disease and their requirements and expectations from treatment. Here, we describe the set-up of this collaborative study and the protocol. Data collection is ongoing.

The protocol includes study design, preparation, conduct and analysis of individual interviews with approximately 80 patients in seven countries (Burkina Faso, Brazil, two sites in Colombia, Iran, Morocco, Peru and Tunisia) where CL is prevalent. Principal investigators and sites were selected through an open call, and two workshops were organised for protocol development and training in conduct and analysis of qualitative health research. Patient recruitment aims at covering a maximum variation of experiences. Transcripts will be analysed to identify outcomes and eligibility criteria as well as further topics that are expected to emerge from the interviews, such as direct and indirect costs related to CL, its psychological impact, preferred modes of drug administration and traditional treatments.

Ethics and dissemination

The study received ethical approval by the responsible committees of each of the participating institutions. Findings will be disseminated through publication in peer-reviewed journals, scientific meetings and to participants and their communities.

https://ift.tt/2LWmCxU

The COMMAND trial of cognitive therapy for harmful compliance with command hallucinations (CTCH): a qualitative study of acceptability and tolerability in the UK

Objectives

To explore service user experiences of a 9-month cognitive behavioural therapy for command hallucinations in the context of a randomised controlled trial including their views on acceptability and tolerability of the intervention.

Design

Qualitative study using semistructured interviews.

Setting

The study took place across three sites: Birmingham, Manchester and London. Interviews were carried out at the sites where therapy took place which included service bases and participants' homes.

Participants

Of 197 patients who consented to the trial, 98 received the Cognitive Behavior Therapy for Command Hallucinations (CTCH) intervention; 25 (15 males) of whom were randomly selected and consented to the qualitative study. The mean age of the sample was 42 years, and 68% were white British.

Results

Two superordinate themes were identified: participants' views about the aspects of CTCH they found most helpful; and participants' concerns with therapy. Helpful aspects of the therapy included gaining control over the voices, challenging the power and omniscience of the voices, following a structured approach, normalisation and mainstreaming of the experience of voices, and having peer support alongside the therapy. Concerns with the therapy included anxiety about completing CTCH tasks, fear of talking back to voices, the need for follow-up and ongoing support and concerns with adaptability of the therapy.

Conclusions

Interpretation: CTCH was generally well received and the narratives validated the overall approach. Participants did not find it an easy therapy to undertake as they were challenging a persecutor they believed had great power to harm; many were concerned, anxious and occasionally disappointed that the voices did not disappear altogether. The trusting relationship with the therapist was crucial. The need for continued support was expressed.

Trial registration number

ISRCTN62304114, Pre-results.

https://ift.tt/2t2AbEN

Long weekly working hours and ischaemic heart disease: a follow-up study among 145 861 randomly selected workers in Denmark

Objectives

The aim of the present study was to test if incidences of ischaemic heart disease (IHD) and usage of antihypertensive drugs are independent of weekly working hours (WWH) among full-time employees in Denmark.

Design and participants

Data on WWH from participants of the Danish labour force surveys, 1999–2013, were linked on an individual level to national registers with data on socioeconomic status (SES), industry, emigrations, redeemed prescriptions, hospital contacts and deaths. Participants were followed until the end of 2014 (on average 7.7 years). Poisson regression was used to model incidence rates as a function of WWH. The analyses were controlled for calendar time, time passed since start of follow-up, employment in the healthcare industry, age, sex, SES and night work.

Results

In total, we found 3635 cases of IHD and 20 648 cases of antihypertensive drug usage. The rate ratio of IHD was 0.95 (95% CI 0.85 to 1.06) for 41–48 compared with 32–40 WWH and 1.07 (0.94 to 1.21) for >48 compared with 32–40 WWH. The corresponding rate ratios for antihypertensive drug usage were 0.99 (0.95 to 1.04) and 1.02 (0.97 to 1.08). No statistically significant interactions between WWH and sex, SES and night work, respectively, were found.

Conclusion

In this Danish sample, we did not find any statistically significant association between WWH and IHD or antihypertensive drug usage.

https://ift.tt/2LVGyRl