Found 10102 matches for
Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review
<jats:sec><jats:title>Objectives</jats:title><jats:p>To understand <jats:italic>how</jats:italic> and <jats:italic>why</jats:italic> effective multi-chronic disease management interventions influence health outcomes in older adults 65 years of age or older.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>A realist review.</jats:p></jats:sec><jats:sec><jats:title>Data sources</jats:title><jats:p>Electronic databases including Medline and Embase (inception to December 2017); and the grey literature.</jats:p></jats:sec><jats:sec><jats:title>Eligibility criteria for selecting studies</jats:title><jats:p>We considered any studies (ie, experimental quasi-experimental, observational, qualitative and mixed-methods studies) as long as they provided data to explain our programme theories and effectiveness review (published elsewhere) findings. The population of interest was older adults (age ≥65 years) with two or more chronic conditions.</jats:p></jats:sec><jats:sec><jats:title>Analysis</jats:title><jats:p>We used the Realist And MEta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and publication criteria for our synthesis aimed at refining our programme theories such that they contained multiple context-mechanism-outcome configurations describing the ways different mechanisms fire to generate outcomes. We created a 3-step synthesis process grounded in meta-ethnography to separate units of data from articles, and to derive explanatory statements across them.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>106 articles contributed to the analysis. We refined our programme theories to explain multimorbidity management in older adults: (1) care coordination interventions with the best potential for impact are team-based strategies, <jats:italic>disease management</jats:italic> programmes and <jats:italic>case management</jats:italic>; (2) optimised disease prioritisation involves ensuring that clinician work with patients to identify what symptoms are problematic and why, and to explore options that are acceptable to both clinicians and patients and (3) optimised patient self-management is dependent on patients’ capacity for selfcare and to what extent, and establishing what patients need to enable selfcare.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>To optimise care, both clinical management and patient self-management need to be considered from multiple perspectives (patient, provider and system). To mitigate the complexities of multimorbidity management, patients focus on reducing symptoms and preserving quality of life while providers focus on the condition that most threaten morbidity and mortality.</jats:p></jats:sec><jats:sec><jats:title>PROSPERO registration number</jats:title><jats:p>CRD42014014489.</jats:p></jats:sec>
<jats:p>As antibiotic consumption grows, bacteria are becoming increasingly resistant to treatment. Antibiotic resistance undermines much of modern health care, which relies on access to effective antibiotics to prevent and treat infections associated with routine medical procedures. The resulting challenges have much in common with those posed by climate change, which economists have responded to with research that has informed and shaped public policy. Drawing on economic concepts such as externalities and the principal–agent relationship, we suggest how economics can help to solve the challenges arising from increasing resistance to antibiotics. We discuss solutions to the key economic issues, from incentivizing the development of effective new antibiotics to improving antibiotic stewardship through financial mechanisms and regulation.</jats:p>
© The Author(s) 2018. Using a unique dataset and a nonparametric decomposition, we determine whether immigrants with native names, immigrants with foreign names, and natives have different outcomes in Spain’s housing market. Results suggest that immigrants with native names achieve greater discounts relative to immigrants with non-Spanish names. As a robustness check, we prove that this is not due to the country of birth. We observe that most of the difference in price across immigrant groups remains unexplained, which may imply some form of discrimination (pure or statistical) against immigrants with non-native names.
Limited evidence for diagnosing bacterial skin infections in older adults in primary care: Systematic review 11 Medical and Health Sciences 1103 Clinical Sciences 11 Medical and Health Sciences 1117 Public Health and Health Services
© 2019 The Author(s). Background: Older adults with bacterial skin infections may present with atypical symptoms, making diagnosis difficult. There is limited authoritative guidance on how older adults in the community present with bacterial skin infections. To date there have been no systematic reviews assessing the diagnostic value of symptoms and signs in identifying bacterial skin infections in older adults in the community. Methods: We searched Medline and Medline in process, Embase and Web of Science, from inception to September 2017. We included cohort and cross-sectional studies assessing the diagnostic accuracy of symptoms and signs in predicting bacterial skin infections in adults in primary care aged over 65 years. The QUADAS-2 tool was used to assess study quality. Results: We identified two observational studies of low-moderate quality, with a total of 7991 participants, providing data to calculate the diagnostic accuracy of 5 unique symptoms in predicting bacterial skin infections. The presence of wounds [LR+: 7.93 (CI 4.81-13.1)], pressure sores [LR+: 4.85 (CI 2.18-10.8)] and skin ulcers [LR+: 6.26 (CI 5.49-7.13)] help to diagnose bacterial skin infections. The presence of urinary incontinence does not help to predict bacterial skin infections (LR + 's of 0.99 and 1.04; LR-'s of 0.96 and 1.04). Conclusions: Currently, there is insufficient evidence to inform the diagnosis of bacterial skin infections in older adults in the community; clinicians should therefore rely upon their clinical judgement and experience. Evidence from high quality primary care studies in older adults, including studies assessing symptoms traditionally associated with bacterial skin infections (e.g. erythema and warmth), is urgently needed to guide practice.
© 2016 Massachusetts Medical Society. BACKGROUND The role of image-guided surveillance as compared with planned neck dissection in the treatment of patients with squamous-cell carcinoma of the head and neck who have advanced nodal disease (stage N2 or N3) and who have received chemoradiotherapy for primary treatment is a matter of debate. METHODS In this prospective, randomized, controlled trial, we assessed the noninferiority of positron- emission tomography-computed tomography (PET-CT)-guided surveillance (performed 12 weeks after the end of chemoradiotherapy, with neck dissection performed only if PET-CT showed an incomplete or equivocal response) to planned neck dissection in patients with stage N2 or N3 disease. The primary end point was overall survival. RESULTS From 2007 through 2012, we recruited 564 patients (282 patients in the planned-surgery group and 282 patients in the surveillance group) from 37 centers in the United Kingdom. Among these patients, 17% had nodal stage N2a disease and 61% had stage N2b disease. A total of 84% of the patients had oropharyngeal cancer, and 75% had tumor specimens that stained positive for the p16 protein, an indicator that human papillomavirus had a role in the causation of the cancer. The median follow-up was 36 months. PET-CT-guided surveillance resulted in fewer neck dissections than did planned dissection surgery (54 vs. 221); rates of surgical complications were similar in the two groups (42% and 38%, respectively). The 2-year overall survival rate was 84.9% (95% confidence interval [CI], 80.7 to 89.1) in the surveillance group and 81.5% (95% CI, 76.9 to 86.3) in the planned-surgery group. The hazard ratio for death slightly favored PET-CT-guided surveillance and indicated noninferiority (upper boundary of the 95% CI for the hazard ratio, <1.50; P = 0.004). There was no significant difference between the groups with respect to p16 expression. Quality of life was similar in the two groups. PET-CT-guided surveillance, as compared with neck dissection, resulted in savings of £1,492 (approximately $2,190 in U.S. dollars) per person over the duration of the trial. CONCLUSIONS Survival was similar among patients who underwent PET-CT-guided surveillance and those who underwent planned neck dissection, but surveillance resulted in considerably fewer operations and it was more cost-effective. (Funded by the National Institute for Health Research Health Technology Assessment Programme and Cancer Research UK; PET-NECK Current Controlled Trials number, ISRCTN13735240.).
Relative toxicity of mood stabilisers and antipsychotics: Case fatality and fatal toxicity associated with self-poisoning
© 2018 The Author(s). Background: Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour. Method: Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005-2012. Results: There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16-4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69-39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01-0.47). Conclusions: There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.
The internal validation of weight and weight change coding using weight measurement data within the UK primary care electronic health record
© 2019 Nicholson et al. Purpose: To use recorded weight values to internally validate weight status and weight change coding in the primary care Electronic Health Record (EHR). Patients and methods: We included adult patients with weight-related Read codes recorded in the UK’s Clinical Practice Research Datalink EHR between 2000 and 2017. Weight status codes were compared to weight values recorded on the same day and positive predictive values (PPVs) were calculated for commonly used codes. Weight change codes were validated using three methods: the percentage (%) difference in kilograms at the time of the code and 1) the previous weight measurement, 2) the weight predicted using linear regression, and 3) the historic mean weight. Weight change codes were validated if estimates were consistent across two out of three methods. Results: A total of 8,108,481 weight codes were recorded in 1,000,002 patients’ EHR. Twice as many were recorded in females (n=5,208,593, 64%). The mean body mass index for “over-weight” codes ranged from 31.9 kg/m 2 to 46.9 kg/m 2 and from 17.4 kg/m 2 to 19.2 kg/m 2 for “underweight” codes. PPVs for the most commonly used weight status codes ranged from 81.3% (80%–82.5%) to 99.3% (99.2%–99.4%). Across the estimation methods, and using only validated weight change codes, mean weight loss ranged from – 5.2% (SD 5.8%) to –7.9% (SD 7.3%) and mean weight gain from 4.2 % (SD 5.5%) to 7.9 % (SD 8.2%). The previous and predicted weight methods were most consistent. Conclusion: We have developed an internationally applicable methodology to internally validate weight-related EHR coding by using available weight measurement data. We demonstrate the UK Read codes that can be confidently used to classify weight status and weight change in the absence of weight values. We provide the first evidence from primary care that a Read code for unexpected weight loss represents a mean loss of ≥ 5 % in a 6-month period, which was broadly consistent across age groups and gender.
“She’s gone now.” A mixed methods analysis of the experiences and perceptions around the deaths of children who died unexpectedly in health care facilities in Cape Town, South Africa
© 2019 Hodkinson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Purpose The sudden death of a child is a catastrophic event for both the family and the healthcare workers involved. Confidential enquiries provide a biomedical depiction of the processes and quality of care delivered and drive improvements in care. However, these rarely include an assessment of the patient/caregiver experience which is increasingly regarded as a key measure of quality of care. Methods A parallel convergent mixed methods design was used to compare and contrast medically-assessed clinical quality of care with caregiver perceptions of quality and care in a cohort of sudden childhood deaths in emergency facilities in Cape Town, South Africa. Results Amongst the 29 sudden childhood deaths, clinical quality of care was assessed as poor in 11 (38%) and the death was considered avoidable or potentially avoidable in 16 (55%). The main themes identified from the caregivers were their perception of the quality of care delivered (driven by perceived healthcare worker effort, empathy and promptness), the way the family was dealt with during the final resuscitation, and communications at the time of and after the death. Ten (35%) caregivers were predominantly negative about the care delivered, of whom four received fair clinical quality of care; 13 (49%) of caregivers had predominantly positive experiences, one of whom received poor clinical quality of care. Conclusions Caregivers’ experiences of the healthcare service around their child’s death are influenced largely by the way healthcare workers communicate with them, as well as the perceived clinical effort. This is not always concordant with the clinically assessed quality of care. Simple interventions such as protocols and education of healthcare workers in dealing with families of a dying or deceased child could improve families’ experiences at a time when they are most vulnerable.
All-terrain vehicle serious injuries and death in children and youth: A national survey of canadian paediatricians
© The Author(s) 2018. Background: All-Terrain Vehicles (ATVs) are a leading cause of serious injury in children and youth. Certain Canadian regions have implemented legislation to promote safety, including age restrictions, mandatory training and helmet use. Jurisdictions with more stringent ATV safety legislation have been shown to have reduced injury rates in the short term. Objectives: To estimate the burden of ATV-related serious injury and death in Canada and to identify Canadian physicians' knowledge of ATV-related legislation, safety and health promotion practices. Methods: A one-time survey was distributed to practicing paediatricians and paediatric subspecialists participating in the Canadian Paediatric Surveillance Program (CPSP) in October 2016. Results: Of 2793 physicians contacted, 904 responded (32.4%). There were 181 reported cases of serious and/or fatal ATV-related injuries, including 6 deaths. Children aged 10 to 14 represented the most number of cases (n=82, 45.3%), followed by 15 to 19 (n=48, 26.5%) and 5 to 9 (n=40, 22.1%). Most cases occurred in July/August (48.3%) and May/June (25.2%), were in males (n=133, 78.2%), and occurred during recreational activity (n=139, 83.2%) or organized racing (n=6, 3.6%). In 99 cases (58.9%), the child was the driver of the ATV. Only two-thirds of respondents (67.5%) knew that ATVs should not carry passengers while under half (42.2%) never discussed ATV safety with their patients. Conclusions: ATV-related injuries and deaths in Canadian children remain a serious public health problem. Education of health care practitioners, including paediatricians, is needed to promote safety. Despite efforts to reduce ATV-related injuries, there remains a significant number of serious injuries and/deaths related to their use.
Communication with children and adolescents about the diagnosis of a life-threatening condition in their parent.
Many adults diagnosed with a life-threatening condition have children living at home; they and their partners face the dual challenge of coping with the diagnosis while trying to maintain a parenting role. Parents are often uncertain about how, when, and what to tell their children about the condition, and are fearful of the effect on their family. There is evidence that children are often aware that something is seriously wrong and want honest information. Health-care professionals have a key role in supporting and guiding parents and caregivers to communicate with their children about the diagnosis. However, the practical and emotional challenges of communicating with families are compounded by a scarcity of evidence-based guidelines. This Review considers children's awareness and understanding of their parents' condition, the effect of communication around parental life-threatening condition on their wellbeing, factors that influence communication, and the challenges to achieving effective communication. Children's and parents' preferences about communication are outlined. An expert workshop was convened to generate principles for health-care professionals, intended as practical guidance in the current absence of empirically derived guidelines.
Communication with children and adolescents about the diagnosis of their own life-threatening condition.
When a child is diagnosed with a life-threatening condition, one of the most challenging tasks facing health-care professionals is how to communicate this to the child, and to their parents or caregivers. Evidence-based guidelines are urgently needed for all health-care settings, from tertiary referral centres in high-income countries to resource limited environments in low-income and middle-income countries, where rates of child mortality are high. We place this Review in the context of children's developing understanding of illness and death. We review the effect of communication on children's emotional, behavioural, and social functioning, as well as treatment adherence, disease progression, and wider family relationships. We consider the factors that influence the process of communication and the preferences of children, families, and health-care professionals about how to convey the diagnosis. Critically, the barriers and challenges to effective communication are explored. Finally, we outline principles for communicating with children, parents, and caregivers, generated from a workshop of international experts.
Italian validation of the Sleep Condition Indicator: A clinical screening tool to evaluate Insomnia Disorder according to DSM-5 criteria
© 2015 Elsevier B.V. Study objectives: The present study investigated the validity, reliability and, as novel aspects, the temporal stability and discriminant validity of the Italian version of the Sleep Condition Indicator (SCI), a new brief tool to appraise Insomnia Disorder (ID) according to the new criteria of the DSM-5. Methods: Subjects with ID (DSM-5), Obstructive Sleep Apnea Syndrome (OSAS) (ICSD3) and a group of healthy subjects (H) were recruited. At the first evaluation (T1), SCI, the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI) were administered. ID patients also completed the SCI 2. months later (T2). Statistical analyses included Cronbach's alpha co-efficient calculation, Intraclass Correlation, Receiver Operating Characteristic (ROC) curves and Pearson correlations. Results: Eighty-eight ID (n= 50. F, mean age 49.9 ± 15.1. years), 43 OSAS (n= 22. F, mean age 50.2 ± 9.1. years) and 40. H (n= 22. F, 49.3 ± 13. years) were recruited at T1. SCI, PSQI and ISI scores were significantly higher in the ID group vs H and OSAS (both p. <. .001). ROC analysis revealed cut off of >. 18 to correctly identify 100% of H, cut off of >. 17 the 100% of OSAS and <. 17 the 100% of ID. Cronbach's alpha were 0.71 at T0, 0.78 at T2 for ID, 0.76 and 0.81 respectively for H and OSAS. SCI showed a negative correlation with ISI (p. <. .01) and PSQI (p. <. .05). Conclusion: The Italian version of SCI shows good internal consistency, temporal stability and concurrent validity in insomnia, confirming data on the original version. Importantly, the present study shows that the SCI effectively discriminates insomnia from both normal sleep and OSAS.
BACKGROUND: In 2018, a so-called crisis developed in the international network of systematic reviewers known as Cochrane. It was widely depicted in terms of two competing narratives-"bad behaviour" by one member of Cochrane's Governing Board and scientific and moral decline within Cochrane. OBJECTIVE: Our goal was to distil insights on the structural issues underpinning the crisis, without taking a definitive position on the accuracy of either narrative. APPROACH AND DATASET: In this paper, we draw on (among other theories) Becker's notion of moral entrepreneurship and Foucault's conceptualisation of power to analyse the claims and counterclaims made by different parties. Our dataset consisted of publicly available materials (blogs, journal articles, newspaper articles) to end 2018, notably those relating to the expulsion of one Governing Board member. MAIN FINDINGS: Both narratives include strong moral claims about the science of systematic review and the governance of scientific organizations. The expelled individual and his supporters defined good systematic reviews in terms of a particular kind of methodological rigour and elimination of bias, and good governance largely in terms of measures to achieve independence from industry influence. Most of Cochrane's Governing Board and their sympathizers evaluated systematic reviews according to a broader range of criteria, incorporating factors such as attention to relationships among reviewers and reflexivity and dialogue around scientific and other judgements. They viewed governance partly in terms of accountability to an external advisory group. Power-knowledge alignments in Cochrane have emerged from, and contributed to, a particular system of meaning which is now undergoing evolution and challenge. CONCLUSION: Polarizing Cochrane's "crisis" into two narratives, only one of which is true, is less fruitful than viewing it in terms of a duality consisting of tensions between the two positions, each of which has some validity. Having framed the conflict as primarily philosophical and political rather than methodological and procedural, we suggest how Cochrane and its supporters and critics might harness their tensions productively.