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Dinh TS, Hanf M, Klein AA, Brueckle MS, Rietschel L, Petermann J, Brosse F, Schulz-Rothe S, Klasing S, Muth C, Seidling H, Engler J, Mergenthal K, Voigt K, van den Akker M. Informational continuity of medication management in transitions of care: Qualitative interviews with stakeholders from the HYPERION-TransCare study. PLoS One 2024; 19:e0300047. [PMID: 38573912 PMCID: PMC10996284 DOI: 10.1371/journal.pone.0300047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/20/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND The transition of patients between inpatient and outpatient care can lead to adverse events and medication-related problems due to medication and communication errors, such as medication discontinuation, the frequency of (re-)hospitalizations, and increased morbidity and mortality. Older patients with multimorbidity and polypharmacy are particularly at high risk during transitions of care. Previous research highlighted the need for interventions to improve transitions of care in order to support information continuity, coordination, and communication. The HYPERION-TransCare project aims to improve the continuity of medication management for older patients during transitions of care. METHODS AND FINDINGS Using a qualitative design, 32 expert interviews were conducted to explore the perspectives of key stakeholders, which included healthcare professionals, patients and one informal caregiver, on transitions of care. Interviews were conducted between October 2020 and January 2021, transcribed verbatim and analyzed using content analysis. We narratively summarized four main topics (stakeholders' tasks, challenges, ideas for solutions and best practice examples, and patient-related factors) and mapped them in a patient journey map. Lacking or incomplete information on patients' medication and health conditions, inappropriate communication and collaboration between healthcare providers within and across settings, and insufficient digital support limit the continuity of medication management. CONCLUSIONS The study confirms that medication management during transitions of care is a complex process that can be compromised by a variety of factors. Legal requirements and standardized processes are urgently needed to ensure adequate exchange of information and organization of medication management before, during and after hospital admissions. Despite the numerous barriers identified, the findings indicate that involved healthcare professionals from both the inpatient and outpatient care settings have a common understanding.
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Affiliation(s)
- Truc Sophia Dinh
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Maria Hanf
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Astrid-Alexandra Klein
- Department of General Practice/Medical Clinic III, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Maria-Sophie Brueckle
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Lisa Rietschel
- Department of General Practice/Medical Clinic III, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jenny Petermann
- Department of General Practice/Medical Clinic III, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Franziska Brosse
- Department of General Practice/Medical Clinic III, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Sylvia Schulz-Rothe
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Sophia Klasing
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Christiane Muth
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of General Practice and Family Medicine, Medical School Westphalia, Bielefeld University, Bielefeld, Germany
| | - Hanna Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Jennifer Engler
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Karen Voigt
- Department of General Practice/Medical Clinic III, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Marjan van den Akker
- Institute of General Practice, Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- Department of Public Health and Primary Care, Academic Centre of General Practice, KU Leuven, Leuven, Belgium
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Xantus G, Burke D, Kanizsai P. Previously undiagnosed scoliosis presenting as pleuritic chest pain in the emergency department - a case series and a validating retrospective audit. BMC Emerg Med 2021; 21:62. [PMID: 34001003 PMCID: PMC8130124 DOI: 10.1186/s12873-021-00455-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/05/2021] [Indexed: 12/02/2022] Open
Abstract
Background Chest pain is one of the commonest presenting complaints in urgent/emergency care, with a lifelong prevalence of up to 25% in the adult population. Pleuritic chest pain is a subset of high investigation burden because of a diverse range of possible causes varying from simple musculoskeletal conditions to pulmonary embolism. Case series Among otherwise fit and healthy adult patients presenting in our emergency department with sudden onset of unilateral pleuritic chest pain, within 1 month we identified a cohort of five patients with pin-point tenderness in one specific costo-sternal joint often with referred pain to the back. All cases had apparent and, previously undiagnosed mild/moderate scoliosis. Methods To confirm and validate the observed association between scoliosis and pleuritic chest pain, a retrospective audit was designed and performed using the hospital’s electronic medical record system to reassess all consecutive adult chest pain patients. Results The Odds Ratio for having chest pain with scoliosis was 30.8 [95%CI 1.71–553.37], twenty times higher than suggested by prevalence data. Discussion In scoliosis the pathologic lateral curvature of the spine adversely affects the functional anatomy of both the spine and ribcage. In our hypothesis the chest wall asymmetry enables minor slip/subluxation of a rib either in the costo-sternal and/or costovertebral junction exerting direct pressure on the intercostal nerve causing pleuritic pain. Conclusion Thorough physical examination of the anterior and posterior chest wall is key to identify underlying scoliosis in otherwise fit patients presenting with sudden onset of pleuritic pain. Incorporating assessment for scoliosis in the low-risk chest pain protocols/tools may help reducing the length of stay in the emergency department and, facilitate speedy but safe discharge with increased patient satisfaction.
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Affiliation(s)
- Gabor Xantus
- Clinical Centre, University of Pécs, Pecs, Hungary.
| | - Derek Burke
- Gibraltar University, Gibraltar, GX11 1AA, Gibraltar
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Smith CF, Kristensen BM, Andersen RS, Hobbs FR, Ziebland S, Nicholson BD. GPs' use of gut feelings when assessing cancer risk: a qualitative study in UK primary care. Br J Gen Pract 2021; 71:e356-e363. [PMID: 33753347 PMCID: PMC7997673 DOI: 10.3399/bjgp21x714269] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/01/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The use of gut feelings to guide clinical decision making in primary care has been frequently described but is not considered a legitimate reason for cancer referral. AIM To explore the role that gut feeling plays in clinical decision making in primary care. DESIGN AND SETTING Qualitative interview study with 19 GPs in Oxfordshire, UK. METHOD GPs who had referred patients to a cancer pathway based on a gut feeling as a referral criterion were invited to participate. Interviews were conducted between November 2019 and January 2020, and transcripts were analysed using the one sheet of paper method. RESULTS Gut feeling was seen as an essential part of decision making that facilitated appropriate and timely care. GPs distanced their gut feelings from descriptions that could be seen as unscientific, describing successful use as reliant on experience and clinical knowledge. This was especially true for patients who fell within a 'grey area' where clinical guidelines did not match the GP's assessment of cancer risk, either because the guidance inadequately represented or did not include the patient's presentation. GPs sought to legitimise their gut feelings by gathering objective clinical evidence, careful examination of referral procedures, and consultation with colleagues. CONCLUSION GPs described their gut feelings as important to decision making in primary care and a necessary addition to clinical guidance. The steps taken to legitimise their gut feelings matched that expected in good clinical practice.
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Affiliation(s)
| | - Benedikte Møller Kristensen
- Research Unit for General Practice, Department of Public Health, Aarhus University and University of Copenhagen, Denmark
| | - Rikke Sand Andersen
- Institute for Public Health - General Practice, University of Southern Denmark, Odense, Denmark
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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4
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Stain N, Cheshire A, Ross C, Ridge D. An Exploration of the help-seeking experiences of patients in an allied professions-led rapid access chest pain pathway: a qualitative study. BMJ Open 2020; 10:e040468. [PMID: 33444203 PMCID: PMC7678391 DOI: 10.1136/bmjopen-2020-040468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE A number of studies have explored delayed help-seeking practices for acute coronary syndrome (ACS) and have indentified multiple intersecting factors which may play a role, for example, attributing symptoms, age, gender, ethnicity and contextual influences. However, the pathway to diagnosis for suspected coronary heart disease (CHD) symptoms in a rapid access chest pain clinic (RACPC) context is underexplored. The objective of this study was to examine patients' help-seeking experiences of accessing RACPC services, from the point at which they notice and interpret symptoms, to their decision to seek help from their general practitioner. DESIGN Qualitative study. SETTING Interviews were conducted in the RACPC at Queen Mary's Roehampton Hospital, London, UK. PARTICIPANTS Maximum variation sampling was used to recruit 30 participants (15 men and 15 women) referred to a RACPC, using sampling dimensions of age, ethnicity and occupation. METHODS Semi-structured interviews focussed on the patient experience of their pathway to the RACPC. Thematic analysis was used to analyse the interview data. RESULTS Participant interpretation of symptoms was shaped by multiple influences; reluctance to seek help contributed to delay; various factors acted as drivers as well as barriers to help-seeking; and GP referrals to RACPC were based on symptoms as well as patients' need for reassurance. CONCLUSION We found complex issues shaped the patient's decision-making when accessing the RACPC, including making sense of symptoms and help-seeking practices. These findings can be used to develop health promotion literature to encourage early help-seeking and improve RACPC services.
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Affiliation(s)
- Nolan Stain
- Cardiac Physiology, Barts Health NHS Trust, London, UK
| | - Anna Cheshire
- College of Liberal Arts and Sciences, University of Westminster, London, UK
| | - Catherine Ross
- The Office of Chief Scientific Officer, NHS England, London, UK
| | - Damien Ridge
- College of Liberal Arts and Sciences, University of Westminster, London, UK
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5
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Smith CF, Drew S, Ziebland S, Nicholson BD. Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence. Br J Gen Pract 2020; 70:e612-e621. [PMID: 32839162 PMCID: PMC7449376 DOI: 10.3399/bjgp20x712301] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Growing evidence for the role of GPs' gut feelings in cancer diagnosis raises questions about their origin and role in clinical practice. AIM To explore the origins of GPs' gut feelings for cancer, their use, and their diagnostic utility. DESIGN AND SETTING Systematic review and meta-analysis of international research on GPs' gut feelings in primary care. METHOD Six databases were searched from inception to July 2019, and internet searches were conducted. A segregated method was used to analyse, then combine, quantitative and qualitative findings. RESULTS Twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues. The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased. Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval. CONCLUSION GPs' gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs' clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience; they tend to remain poorly recorded and are, therefore, inaccessible to researchers.
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Affiliation(s)
| | - Sarah Drew
- London School of Economics and Political Science, London
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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Barais M, Fossard E, Dany A, Montier T, Stolper E, Van Royen P. Accuracy of the general practitioner's sense of alarm when confronted with dyspnoea and/or chest pain: a prospective observational study. BMJ Open 2020; 10:e034348. [PMID: 32075841 PMCID: PMC7044836 DOI: 10.1136/bmjopen-2019-034348] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES Dyspnoea and chest pain are symptoms shared with multiple pathologies ranging from the benign to life-threatening diseases. A Gut Feelings Questionnaire (GFQ) has been validated to measure the general practitioner's (GPs) sense of alarm or sense of reassurance. The aim of the study was to estimate the diagnostic test accuracy of GPs' sense of alarm when confronted with dyspnoea and chest pain. DESIGN AND SETTINGS Prospective observational study in general practice. PARTICIPANTS Patients aged between 18 and 80 years, consulting their GP for dyspnoea and/or chest pain, were considered for enrolment. These GPs had to complete the GFQ immediately after the consultation. PRIMARY OUTCOME MEASURES Life-threatening and non-life-threatening diseases have previously been defined according to the pathologies or symptoms in the International Classification of Primary Care (ICPC)-2 classification. The index test was the sense of alarm and the reference standard was the final diagnosis at 4 weeks. RESULTS 25 GPs filled in 235 GFQ questionnaires. The positive likelihood ratio for the sense of alarm was 2.12 (95% CI 1.49 to 2.82), the negative likelihood ratio was 0.55 (95% CI 0.37 to 0.77). CONCLUSIONS Where the physician experienced a sense of alarm when a patient consulted him/her for dyspnoea and/or chest pain, the post-test odds that this patient had, in fact, a life-threatening disease was about twice as high as the pretest odds. TRIAL REGISTRATION NUMBER NCT02932982.
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Affiliation(s)
- Marie Barais
- Department of General Practice, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Emilie Fossard
- Department of General Practice, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Antoine Dany
- Department of Public Health, EA 7479 SPURBO, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Tristan Montier
- Inserm UMR1078, Faculté de Médecine et des Sciences de la Santé, Université de Bretagne Occidentale, Brest, Bretagne, France
| | - Erik Stolper
- CAPHRI School for Public Health and Primary Care, University of Maastricht, Maastricht, The Netherlands
- Department of Primary and Interdisciplinary Care, University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Antwerp, Belgium
| | - Paul Van Royen
- Department of Primary and Interdisciplinary Care, University of Antwerp Faculty of Medicine and Health Sciences, Wilrijk, Antwerp, Belgium
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Why do general practitioners not refer patients to behaviour-change programmes after preventive health checks? A mixed-method study. BMC FAMILY PRACTICE 2019; 20:135. [PMID: 31604416 PMCID: PMC6788028 DOI: 10.1186/s12875-019-1028-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/20/2019] [Indexed: 01/08/2023]
Abstract
Background This study was embedded in the Check-In randomised controlled trial that investigated the effectiveness of general practice-based preventive health checks on adverse health behaviour and early detection of non-communicable diseases offered to individuals with low socioeconomic positions. Despite successful recruitment of patients, the intervention had no effect. One reason for the lack of effectiveness could be low rates of referral to behaviour-change programmes in the municipality, resulting in a low dose of the intervention delivered. The aim of this study is to examine the referral pattern of the general practitioners and potential barriers to referring eligible patients to these behaviour-change programmes. Methods A mixed-method design was used, including patients’ questionnaires, recording sheet from the health checks and semi-structured qualitative interviews with general practitioners. All data used in the study were collected during the time of the intervention. Logistic regressions were used to estimate odds ratios for being eligible and for receiving referrals. The qualitative empirical material was analysed thematically. Emerging themes were grouped, discussed and the material was re-read. The themes were reviewed alongside the analysis of the quantitative material to refine and discuss the themes. Results Of the 364 patients, who attended the health check, 165 (45%) were marked as eligible for a referral to behaviour-change programme by their general practitioner and of these, 90 (55%) received referrals. Daily smoking (OR = 3.22; 95% CI:2.01–5.17), high-risk alcohol consumption (OR = 2.66; 95% CI:1.38–5.12), obesity (OR = 2.89; 95% CI:1.61–5.16) and poor lung function (OR = 2.05; 95% CI:1.14–3.70) were all significantly associated with being eligible, but not with receiving referral. Four themes emerged as the main barriers to referring patients to behaviour-change programmes: 1) general practitioners’ responsibility and ownership for their patients, 2) balancing information and accepting a rejection, 3) assessment of the right time for behavioural change and 4) general practitioners’ attitudes towards behaviour-change programmes in the municipality. Conclusion We identified important barriers among the general practitioners which influenced whether the patients received referrals to behaviour-change programmes in the municipality and thereby influenced the dose of intervention delivered in Check-In. The findings suggest that an effort is needed to assist the collaboration between general practices and the municipalities’ primary preventive services. Trial registration Clinical Trials NCT01979107; October 25, 2013.
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Oslislo S, Heintze C, Schmiedhofer M, Möckel M, Schenk L, Holzinger F. How to decide adequately? Qualitative study of GPs' view on decision-making in self-referred and physician-referred emergency department consultations in Berlin, Germany. BMJ Open 2019; 9:e026786. [PMID: 30944138 PMCID: PMC6500203 DOI: 10.1136/bmjopen-2018-026786] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Patients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients' decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs' perception of such patients. This qualitative study explores the GPs' view regarding motives and competences of patients self-referring to EDs, and also GPs' rationale for or against physician-initiated ED referrals. DESIGN Qualitative study with semi-structured, face-to-face interviews; qualitative content analysis. SETTING GP practices in Berlin, Germany. PARTICIPANTS 15 GPs (female/male: 9/6; mean age 53.6 years). RESULTS The interviewed GPs related a wide spectrum of factors potentially influencing their patients' decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients' surmised rationale corresponded to GPs' reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients' health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy. CONCLUSIONS Health education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals. TRIAL REGISTRATION NUMBER DRKS00011930.
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Affiliation(s)
- Sarah Oslislo
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Christoph Heintze
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
| | - Martina Schmiedhofer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Emergency Medicine, Berlin, Germany
| | - Martin Möckel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Emergency Medicine, Berlin, Germany
- James Cook University, The College of Public Health, Medical and Veterinary Sciences, Townsville, Queensland, Australia
| | - Liane Schenk
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Medical Sociology and Rehabilitation Science, Berlin, Germany
| | - Felix Holzinger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Berlin, Germany
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9
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Biesemans L, Cleef LE, Willemsen RTA, Hoorweg BBN, Renier WS, Buntinx F, Glatz JFC, Dinant GJ. Managing chest pain patients in general practice: an interview-based study. BMC FAMILY PRACTICE 2018; 19:80. [PMID: 29859536 PMCID: PMC5985055 DOI: 10.1186/s12875-018-0771-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/21/2018] [Indexed: 11/20/2022]
Abstract
Background Assessment of chest pain in general practice is challenging. General practitioners (GPs) often feel uncertainty when dealing with chest pain. The role of new diagnostic tools is yet unclear. Therefore, we aimed to learn: (1) whether or not GPs experience a change in incidence and presentation of chest pain, (2) how GPs deal with uncertainty, and (3) which thoughts, demands and doubts concerning new diagnostic tools occur. Methods Semi-structured, face to face interview based study, aiming at six main subjects: experienced changes in prevalence of chest pain, the management of chest pain patients, dealing with uncertainty, the GPs’ approach in referring chest pain patients, GPs’ attitude towards ‘unnecessary’ referrals, and the GPs’ suggestions for improving the management of chest pain patients. Results 145 GPs in Belgium and the Netherlands were invited to participate, 27 (15 Flemish and 12 Dutch) GPs were interviewed. Data saturation was reached. The number of patients having an acute coronary syndrome among chest pain patients is decreasing, whereas the presentation of atypical complaints increases, together leading to more uncertainty. GPs rely on their own judgment above all, and desire new diagnostic tools only when these tools are of proven added value. Conclusion The incidence of chest pain in general practice is not decreasing according to the GPs. However, the presentation of chest pain is changing. GPs feel relatively comfortable with referring a considerable number of chest pain patients without ACS, as over-referral is safe. Uncertainty is regarded as a substantial element of their profession. New diagnostic tools are awaited with cautiousness. Electronic supplementary material The online version of this article (10.1186/s12875-018-0771-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leen Biesemans
- Department of Family Medicine, Catholic University Leuven, Leuven, Belgium
| | - Lotte E Cleef
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands
| | - Robert T A Willemsen
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands.
| | - Beatrijs B N Hoorweg
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands
| | - Walter S Renier
- Department of Family Medicine, Catholic University Leuven, Leuven, Belgium
| | - Frank Buntinx
- Department of Family Medicine, Catholic University Leuven, Leuven, Belgium.,Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands
| | - Jan F C Glatz
- Department of Genetics & Cell Biology, Maastricht University, Maastricht, the Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands
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10
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de Vos-Kerkhof E, Geurts DHF, Steyerberg EW, Lakhanpaul M, Moll HA, Oostenbrink R. Characteristics of revisits of children at risk for serious infections in pediatric emergency care. Eur J Pediatr 2018; 177:617-624. [PMID: 29397418 PMCID: PMC5851682 DOI: 10.1007/s00431-018-3095-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 12/14/2017] [Accepted: 01/17/2018] [Indexed: 01/27/2023]
Abstract
UNLABELLED In this study, we aimed to identify characteristics of (unscheduled) revisits and its optimal time frame after Emergency Department (ED) discharge. Children with fever, dyspnea, or vomiting/diarrhea (1 month-16 years) who attended the ED of Erasmus MC-Sophia, Rotterdam (2010-2013), the Netherlands, were prospectively included. Three days after ED discharge, we applied standardized telephonic questionnaires on disease course and revisits. Multivariable logistic regression analysis was used to identify independent characteristics of revisits. Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with revisits (n = 527) in children at risk for serious infections discharged from the ED (n = 1765). Children revisited the ED within a median of 2 days (IQR 1.0-3.0), but this was proven to be shorter in children with vomiting/diarrhea (1.0 day (IQR 1.0-2.0)) compared to children with fever or dyspnea (2.0 (IQR 1.0-3.0)). CONCLUSION Young age, parental concern, and alarming signs and symptoms (chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea) were associated with emergency health care revisits in children with fever, dyspnea, and vomiting/diarrhea. These characteristics could help to define targeted review of children during post-discharge period. We observed a disease specific and differential timing of control revisits after ED discharge. What is Known • Fever, dyspnea, and vomiting/diarrhea are major causes of emergency care attendance in children. • As uncertainty remains on uneventful recovery, patients at risk need to be identified on order to improve safety netting after discharge from the ED. What is New • In children with fever, dyspnea, and vomiting/diarrhea, young age, parental concern and chest wall retractions, ill appearance, clinical signs of dehydration, and tachypnea help to define targeted review of children during the post-discharge period. • A revisit after ED discharge is disease-specific and seems to be shorter for children with vomiting/diarrhea than others.
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Affiliation(s)
- Evelien de Vos-Kerkhof
- grid.416135.4Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
| | - Dorien H. F. Geurts
- grid.416135.4Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
| | - Ewout W. Steyerberg
- 000000040459992Xgrid.5645.2Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Monica Lakhanpaul
- 0000000121901201grid.83440.3bDepartment of Population, Policy and Practice UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, UK
| | - Henriette A. Moll
- grid.416135.4Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
| | - Rianne Oostenbrink
- grid.416135.4Department of General Paediatrics, Erasmus MC-Sophia Children’s Hospital, Wytemaweg 80, 3015 Rotterdam, CN Netherlands
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Clinical Utility of a Precision Medicine Test Evaluating Outpatients with Suspected Obstructive Coronary Artery Disease. Am J Med 2017; 130:482.e11-482.e17. [PMID: 27993573 DOI: 10.1016/j.amjmed.2016.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/26/2016] [Accepted: 11/16/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Identifying patients with obstructive coronary artery disease can be challenging for primary care physicians. Advances in precision medicine may help augment clinical tools and redefine the paradigm for evaluating coronary artery disease in the outpatient setting. A blood-based age/sex/gene expression score (ASGES) incorporating key features of precision medicine has shown clinical validity with a 96% negative predictive value and 89% sensitivity in estimating a symptomatic patient's current likelihood of obstructive coronary artery disease. To better characterize the clinical utility of the ASGES and measure its impact on clinician decision-making, a community-based registry was established. METHODS The prospective PRESET Registry (NCT01677156) enrolled stable, nonacute adult patients presenting with typical or atypical symptoms suggestive of obstructive coronary artery disease from 21 US primary care practices from August 2012 to August 2014. Demographics, clinical characteristics, and ASGES results (predefined as low [ASGES ≤15] or elevated [ASGES >15]) were collected, as were referrals to Cardiology or further functional/anatomic cardiac testing after ASGES testing. Patients were followed for 1 year post ASGES testing. RESULTS Among the 566-patient cohort (median age 56 years), clinicians referred 26/252 (10%) of patients with low scores vs 137/314 (44%) of patients with elevated scores to Cardiology or advanced cardiac testing for further evaluation (unadjusted odds ratio 0.15, P <.0001; adjusted odds ratio after accounting for clinical covariates = 0.18, P <.0001). Data on 84 patients referred for advanced cardiac testing showed abnormal findings in 0 of 13 (0%) low ASGES and 10 of 71 (14%) elevated ASGES patients. Major adverse cardiovascular events and revascularization were noted in 3/252 (1.2%) patients with low ASGES and 14/314 (4.5%) patients with elevated ASGES score (P <.03). CONCLUSIONS In this community-based cardiovascular registry, the ASGES demonstrated clinical utility in the evaluation of patients with suspected obstructive coronary artery disease. Low-score patients were less likely to undergo cardiac referral, were unlikely to have positive findings on further cardiac work-up, and had a low rate of adverse cardiovascular events in 1-year follow-up. Our work provides evidence supporting the value of using precision medicine in the delivery of cardiovascular care.
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Abstract
OBJECTIVES The gut feelings of doctors can act as triggers and modulators of the diagnostic process. This study explored the existence, significance, determinants and triggers of gut feelings among Spanish general practitioners. DESIGN Qualitative study using focus groups. Thematic content analysis. SETTING Primary healthcare centres in Majorca (Spain). PARTICIPANTS 20 purposively sampled general practitioners working in Majorca. RESULTS General practitioners were aware of the existence of gut feelings in their diagnostic reasoning process and recognised 2 kinds of gut feelings: a sense of alarm and a sense of reassurance. A previous physician-patient relationship and the physician's experience had a strong perceived influence on the appearance of gut feelings. The physicians attached great significance to gut feelings, and considered them as a characteristic of the primary care working style and as a tool available in their diagnostic process. The physicians thought that the notion of gut feelings and their relevance can be transmitted to students and trainees. They tended to follow their gut feelings, although they were not sure of their accuracy. CONCLUSIONS Spanish general practitioners in our study recognise the presence and role of gut feelings in their diagnostic reasoning process. Future research should examine the diagnostic accuracy of gut feelings and how to teach about gut feelings in the training of general practitioners.
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Affiliation(s)
- Bernardino Oliva
- Majorca Primary Care Department, Trencadors Primary Health Centre, Llucmajor, Spain
| | - Sebastià March
- Majorca Primary Care Department, Research Unit, Palma de Mallorca, Spain
| | - Cristina Gadea
- Majorca Primary Care Department, Playa de Palma Primary Health Centre, Palma de Mallorca, Spain
| | - Erik Stolper
- Faculty of Health, Medicine and Life Sciences, Department of General Practice, Caphri School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Magdalena Esteva
- Majorca Primary Care Department, Research Unit, Palma de Mallorca, Spain
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13
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Schols AMR, van Boekholt TA, Oversier LMR, Dinant GJ, Cals JWL. General practitioners' experiences with out-of-hours cardiorespiratory consultations: a qualitative study. BMJ Open 2016; 6:e012136. [PMID: 27519924 PMCID: PMC4985977 DOI: 10.1136/bmjopen-2016-012136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To explore general practitioners' (GPs') experiences with and views on the diagnosis and management of patients with cardiorespiratory symptoms during GP out-of-hours care. We also aimed to identify ways of (diagnostic) support during these consultations. DESIGN Qualitative study; face-to-face semistructured interviews. SETTING GP out-of-hours care in the Netherlands. PARTICIPANTS 15 GPs in the province of Limburg, the Netherlands. RESULTS Overall, GPs find cardiorespiratory consultations challenging and difficult. Tension and uncertainty as well as defensive behaviour were the key themes that characterised GPs' experiences. We identified several subthemes underlying the key themes: setting, potentially severe consequences, absence of a pre-existing relationship and little knowledge of the patient's background, difficulties differentiating between possible causes of symptoms, changed public opinion and patient population, and previous experiences. GPs approach cardiorespiratory consultations differently and their threshold for referring patients and performing diagnostic tests is lower. We identified differing views on the use of additional diagnostic tests at GP out-of-hours services. CONCLUSIONS This study sheds further light on how GPs experience cardiorespiratory consultations during out-of-hours care and how this leads to a high number of cardiorespiratory referrals. GPs relate cardiorespiratory consultation during out-of-hours care with tension and uncertainty leading to defensive behaviour, which can be translated into a different approach towards cardiorespiratory consultations and a lower threshold for referring patients and performing diagnostic tests. Opinions on the possible added value of additional diagnostics in reducing the number of referrals should be further investigated, as we identified differing views on the use of additional diagnostic tests at GP out-of-hours services.
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Affiliation(s)
- Angel M R Schols
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Tessa A van Boekholt
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Lex M R Oversier
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Limburg, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, Limburg, The Netherlands
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Vermandere M, Warmenhoven F, Van Severen E, De Lepeleire J, Aertgeerts B. The Ars Moriendi Model for Spiritual Assessment:
A Mixed-Methods Evaluation. Oncol Nurs Forum 2015; 42:E294-301. [DOI: 10.1188/15.onf.294-301] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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15
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Willemsen RTA, Buntinx F, Winkens B, Glatz JF, Dinant GJ. The value of signs, symptoms and plasma heart-type fatty acid-binding protein (H-FABP) in evaluating patients presenting with symptoms possibly matching acute coronary syndrome: background and methods of a diagnostic study in primary care. BMC FAMILY PRACTICE 2014; 15:203. [PMID: 25738970 PMCID: PMC4272772 DOI: 10.1186/s12875-014-0203-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 11/27/2014] [Indexed: 12/16/2022]
Abstract
Background Chest complaints presented to a general practitioner (GP) are frequently caused by diseases which have advantageous outcomes. However, in some cases, acute coronary syndrome (ACS) is present (1.5-22% of cases). The patient’s signs, symptoms and electrocardiography results are insufficient diagnostic tools to distinguish mild disease from ACS. Therefore, most patients presenting chest complaints are referred to secondary care facilities where ACS is then ruled out in a majority of patients (78%). Recently, a point of care test for heart-type fatty acid-binding protein (H-FABP) using a low cut-off value between positive and negative of 4 ng/ml has become available. We aim to study the role of this point of care device in triage of patients presenting chest complaints possibly due to ACS, in primary care. Our research protocol is presented in this article. Results are expected in 2015. Methods/Design Participating GPs will register signs and symptoms in all patients presenting chest complaints possibly due to ACS. Point of care H-FABP testing will also be performed. Our study will be a derivation study to identify signs and symptoms that, combined with point of care H-FABP testing, can be part of an algorithm to either confirm or rule out ACS. The diagnostic value for ACS of this algorithm in general practice will be determined. Discussion A safe diagnostic elimination of ACS by application of the algorithm can be of significant clinical relevance. Improved triage and thus reduction of the number of patients with chest complaints without underlying ACS, that are referred to secondary care facilities, could lead to a substantial cost reduction. Trial registration ClinicalTrials.gov, NCT01826994, accepted April 8th 2013.
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Barais M, Morio N, Cuzon Breton A, Barraine P, Calvez A, Stolper E, Van Royen P, Liétard C. "I can't find anything wrong: it must be a pulmonary embolism": Diagnosing suspected pulmonary embolism in primary care, a qualitative study. PLoS One 2014; 9:e98112. [PMID: 24840333 PMCID: PMC4026480 DOI: 10.1371/journal.pone.0098112] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 04/28/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Before using any prediction rule oriented towards pulmonary embolism (PE), family physicians (FPs) should have some suspicion of this diagnosis. The diagnostic reasoning process leading to the suspicion of PE is not well described in primary care. OBJECTIVE to explore the diagnostic reasoning of FPs when pulmonary embolism is suspected. METHOD Semi-structured qualitative interviews with 28 FPs. The regional hospital supplied data of all their cases of pulmonary embolism from June to November 2011. The patient's FP was identified where he/she had been the physician who had sent the patient to the emergency unit. The first consecutive 14 FPs who agreed to participate made up the first group. A second group was chosen using a purposeful sampling method. The topic guide focused on the circumstances leading to the suspicion of PE. A thematic analysis was performed, by three researchers, using a grounded theory coding paradigm. RESULTS In the FPs' experience, the suspicion of pulmonary embolism arose out of four considerations: the absence of indicative clinical signs for diagnoses other than PE, a sudden change in the condition of the patient, a gut feeling that something was seriously wrong and an earlier failure to diagnose PE. The FPs interviewed did not use rules in their diagnostic process. CONCLUSION This study illustrated the diagnostic role of gut feelings in the specific context of suspected pulmonary embolism in primary care. The FPs used the sense of alarm as a tool to prevent the diagnostic error of missing a PE. The diagnostic accuracy of gut feelings has yet to be evaluated.
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Affiliation(s)
- Marie Barais
- Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France
- * E-mail:
| | - Nathalie Morio
- Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France
| | - Amélie Cuzon Breton
- Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France
| | - Pierre Barraine
- Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France
| | - Amélie Calvez
- Université de Bretagne Occidentale, Faculté de Médecine et des Sciences de la Santé de Brest, Département Universitaire de Médecine Générale, Brest, France
| | - Erik Stolper
- Faculty of Health, Medicine and Life Sciences, Caphri School for Public Health and Primary Care, Department of Family Medicine, Maastricht University, Maastricht, The Netherlands
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Paul Van Royen
- Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Claire Liétard
- Université Européenne de Bretagne, Faculté de Médecine et des Sciences de la Santé de Brest -Laboratoire de Santé Publique, Epidémiologie, Brest, France
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Ladapo JA, Lyons H, Yau M, Rich P, Newton D, Bruce-Mensah K, Johnson A, Zhou Y, Stemkowski S, Monane M. Enhanced Assessment of Chest Pain and Related Symptoms in the Primary Care Setting Through the Use of a Novel Personalized Medicine Genomic Test. Am J Med Qual 2014; 30:345-52. [DOI: 10.1177/1062860614532517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Heather Lyons
- Comprehensive Health Insights, A Humana Company, Louisville, KY
| | - May Yau
- CardioDx, Inc, Palo Alto, CA
| | - Paul Rich
- Comprehensive Physician Associates, Youngstown, OH
| | | | | | | | - Yunping Zhou
- Comprehensive Health Insights, A Humana Company, Louisville, KY
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Tandjung R, Senn O, Rosemann T, Loy M. Diagnosis and management of acute coronary syndrome in an outpatient setting: good guideline adherence in Swiss primary care. J Eval Clin Pract 2013; 19:819-24. [PMID: 22568771 DOI: 10.1111/j.1365-2753.2012.01856.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Switzerland lacks of national guidelines for the initial treatment of an acute coronary syndrome (ACS). ACS is not as frequent in an outpatient setting as in an emergency department; nevertheless, missing an ACS is associated with high morbidity and mortality. We wanted to observe actual infrastructure and performance based on case vignettes in outpatient general practitioners (GPs) and cardiologists (CAs); as a second outcome, we wanted to compare GPs to CAs. METHODS We conducted a postal vignette-based survey to investigate the management of outpatients presenting with acute chest pain by doctors in private practice. The use of troponin and cardiac stress testing for the evaluation of acute chest pain as well as referral practice and use of antiplatelet agents were assessed and compared between GPs and CAs. RESULTS There were 507 of the 571 respondents (response rate 39.7%) who were CAs (36) or GPs (471) and were included in the analysis. Whereas all CAs were equipped with electrocardiogram (ECG), cardiac stress testing and troponin assays, the majority of GPs had an ECG (97.8%) and applied troponin testing (76.3%), and 38.7% performed cardiac stress testing. The vast majority responded to directly refer a STEMI to the next catheter lab (87.7%), or in the case of a troponin-positive NSTEMI, to an inpatient ward (94.1%) with no difference between GPs and CAs. A majority of the GPs responded to use antiplatelet agents in the case of a STEMI (89.6%) and reported further workup with cardiac stress testing in the case of a troponin-negative acute chest pain (78.7%), which was lower compared to CAs who applied antiplatelet agents and cardiac stress testing in 100% and 97.0%. CONCLUSIONS We could show that international guideline adherence in ACS of GPs is high and GPs perform as well as CAs. Nevertheless there is room for optimization in the antiplatelet therapy and the use of cardiac stress testing in a low-risk population. National guidelines for treatment of an ACS in an outpatient setting are indicated.
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Affiliation(s)
- Ryan Tandjung
- Research Associate Assistant Professor Professor, Director, Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland Research Associate, Health Care Ministry of the Canton of Zurich, Zurich, Switzerland
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19
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Stolper CF, Van de Wiel MWJ, De Vet HCW, Rutten ALB, Van Royen P, Van Bokhoven MA, Van der Weijden T, Dinant GJ. Family physicians' diagnostic gut feelings are measurable: construct validation of a questionnaire. BMC FAMILY PRACTICE 2013; 14:1. [PMID: 23281961 PMCID: PMC3565882 DOI: 10.1186/1471-2296-14-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 12/17/2012] [Indexed: 12/02/2022]
Abstract
Background Family physicians perceive that gut feelings, i.e. a ‘sense of reassurance’ or a ‘sense of alarm’, play a substantial role in diagnostic reasoning. A measuring instrument is desirable for further research. Our objective is to validate a questionnaire measuring the presence of gut feelings in diagnostic reasoning. Methods We constructed 16 case vignettes from real practice situations and used the accompanying ‘sense of reassurance’ or the ‘sense of alarm’ as reference labels. Based on the results of an initial study (26 family physicians), we divided the case vignettes into a group involving a clear role for the sense of reassurance or the sense of alarm and a group involving an ambiguous role. 49 experienced family physicians evaluated each 10 vignettes using the questionnaire. Construct validity was assessed by testing hypotheses and an internal consistency procedure was performed. Results As hypothesized we found that the correlations between the reference labels and corresponding items were high for the clear-case vignettes (0.59 – 0.72) and low for the ambiguous-case vignettes (0.08 – 0.23). The agreement between the classification in clear sense of reassurance, clear sense of alarm and ambiguous case vignettes as derived from the initial study and the study population’s judgments was substantial (Kappa = 0.62). Factor analysis showed one factor with opposites for sense of reassurance and sense of alarm items. The questionnaire’s internal consistency was high (0.91). We provided a linguistic validated English-language text of the questionnaire. Conclusions The questionnaire appears to be valid. It enables quantitative research into the role of gut feelings and their diagnostic value in family physicians’ diagnostic reasoning.
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Affiliation(s)
- Christiaan F Stolper
- Caphri School for Public Health and Primary Care, Department of Primary Medicine, Maastricht University, P,O, Box 616, Maastricht, 6200 MD, The Netherlands.
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20
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Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians' gut feeling about serious infections in children: observational study. BMJ 2012; 345:e6144. [PMID: 23015034 PMCID: PMC3458229 DOI: 10.1136/bmj.e6144] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the basis and added value of clinicians' "gut feeling" that infections in children are more serious than suggested by clinical assessment. DESIGN Observational study. SETTING Primary care setting, Flanders, Belgium. PARTICIPANTS Consecutive series of 3890 children and young people aged 0-16 years presenting in primary care. MAIN OUTCOME MEASURES Presenting features, clinical assessment, doctors' intuitive response at first contact with children in primary care, and any subsequent diagnosis of serious infection determined from hospital records. RESULTS Of the 3369 children and young people assessed clinically as having a non-severe illness, six (0.2%) were subsequently admitted to hospital with a serious infection. Intuition that something was wrong despite the clinical assessment of non-severe illness substantially increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and acting on this gut feeling had the potential to prevent two of the six cases being missed (33%, 95% confidence interval 4.0% to 100%) at a cost of 44 false alarms (1.3%, 95% confidence interval 0.95% to 1.75%). The clinical features most strongly associated with gut feeling were the children's overall response (drowsiness, no laughing), abnormal breathing, weight loss, and convulsions. The strongest contextual factor was the parents' concern that the illness was different from their previous experience (odds ratio 36.3, 95% confidence interval 12.3 to 107). CONCLUSIONS A gut feeling about the seriousness of illness in children is an instinctive response by clinicians to the concerns of the parents and the appearance of the children. It should trigger action such as seeking a second opinion or further investigations. The observed association between intuition and clinical markers of serious infection means that by reflecting on the genesis of their gut feeling, clinicians should be able to hone their clinical skills.
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Affiliation(s)
- Ann Van den Bruel
- Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford OX2 6GG, UK.
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21
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Bonilauri Ferreira APR, Ferreira RF, Rajgor D, Shah J, Menezes A, Pietrobon R. Clinical reasoning in the real world is mediated by bounded rationality: implications for diagnostic clinical practice guidelines. PLoS One 2010; 5:e10265. [PMID: 20421920 PMCID: PMC2857648 DOI: 10.1371/journal.pone.0010265] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 03/18/2010] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Little is known about the reasoning mechanisms used by physicians in decision-making and how this compares to diagnostic clinical practice guidelines. We explored the clinical reasoning process in a real life environment. METHOD This is a qualitative study evaluating transcriptions of sixteen physicians' reasoning during appointments with patients, clinical discussions between specialists, and personal interviews with physicians affiliated to a hospital in Brazil. RESULTS FOUR MAIN THEMES WERE IDENTIFIED: simple and robust heuristics, extensive use of social environment rationality, attempts to prove diagnostic and therapeutic hypothesis while refuting potential contradictions using positive test strategy, and reaching the saturation point. Physicians constantly attempted to prove their initial hypothesis while trying to refute any contradictions. While social environment rationality was the main factor in the determination of all steps of the clinical reasoning process, factors such as referral letters and number of contradictions associated with the initial hypothesis had influence on physicians' confidence and determination of the threshold to reach a final decision. DISCUSSION Physicians rely on simple heuristics associated with environmental factors. This model allows for robustness, simplicity, and cognitive energy saving. Since this model does not fit into current diagnostic clinical practice guidelines, we make some propositions to help its integration.
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Affiliation(s)
| | | | - Dimple Rajgor
- Duke-NUS Graduate Medical School, Singapore, Singapore
- Research on Research group, Duke University, Durham, North Carolina, United States of America
| | - Jatin Shah
- Duke-NUS Graduate Medical School, Singapore, Singapore
- Research on Research group, Duke University, Durham, North Carolina, United States of America
| | | | - Ricardo Pietrobon
- Duke-NUS Graduate Medical School, Singapore, Singapore
- Duke University Health System, Durham, North Carolina, United States of America
- Research on Research group, Duke University, Durham, North Carolina, United States of America
- * E-mail:
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Verdon F, Junod M, Herzig L, Vaucher P, Burnand B, Bischoff T, Pécoud A, Favrat B. Predictive ability of an early diagnostic guess in patients presenting with chest pain; a longitudinal descriptive study. BMC FAMILY PRACTICE 2010; 11:14. [PMID: 20170544 PMCID: PMC2836993 DOI: 10.1186/1471-2296-11-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 02/21/2010] [Indexed: 11/16/2022]
Abstract
Background The intuitive early diagnostic guess could play an important role in reaching a final diagnosis. However, no study to date has attempted to quantify the importance of general practitioners' (GPs) ability to correctly appraise the origin of chest pain within the first minutes of an encounter. Methods The validation study was nested in a multicentre cohort study with a one year follow-up and included 626 successive patients who presented with chest pain and were attended by 58 GPs in Western Switzerland. The early diagnostic guess was assessed prior to a patient's history being taken by a GP and was then compared to a diagnosis of chest pain observed over the next year. Results Using summary measures clustered at the GP's level, the early diagnostic guess was confirmed by further investigation in 51.0% (CI 95%; 49.4% to 52.5%) of patients presenting with chest pain. The early diagnostic guess was more accurate in patients with a life threatening illness (65.4%; CI 95% 64.5% to 66.3%) and in patients who did not feel anxious (62.9%; CI 95% 62.5% to 63.3%). The predictive abilities of an early diagnostic guess were consistent among GPs. Conclusions The GPs early diagnostic guess was correct in one out of two patients presenting with chest pain. The probability of a correct guess was higher in patients with a life-threatening illness and in patients not feeling anxious about their pain.
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Affiliation(s)
- François Verdon
- Institute of General Medicine, University of Lausanne, Bugnon 44, 1011 Lausanne, Switzerland
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Gencer B, Vaucher P, Herzig L, Verdon F, Ruffieux C, Bösner S, Burnand B, Bischoff T, Donner-Banzhoff N, Favrat B. Ruling out coronary heart disease in primary care patients with chest pain: a clinical prediction score. BMC Med 2010; 8:9. [PMID: 20092615 PMCID: PMC2832616 DOI: 10.1186/1741-7015-8-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2009] [Accepted: 01/21/2010] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Chest pain raises concern for the possibility of coronary heart disease. Scoring methods have been developed to identify coronary heart disease in emergency settings, but not in primary care. METHODS Data were collected from a multicenter Swiss clinical cohort study including 672 consecutive patients with chest pain, who had visited one of 59 family practitioners' offices. Using delayed diagnosis we derived a prediction rule to rule out coronary heart disease by means of a logistic regression model. Known cardiovascular risk factors, pain characteristics, and physical signs associated with coronary heart disease were explored to develop a clinical score. Patients diagnosed with angina or acute myocardial infarction within the year following their initial visit comprised the coronary heart disease group. RESULTS The coronary heart disease score was derived from eight variables: age, gender, duration of chest pain from 1 to 60 minutes, substernal chest pain location, pain increasing with exertion, absence of tenderness point at palpation, cardiovascular risks factors, and personal history of cardiovascular disease. Area under the receiver operating characteristics curve was of 0.95 with a 95% confidence interval of 0.92; 0.97. From this score, 413 patients were considered as low risk for values of percentile 5 of the coronary heart disease patients. Internal validity was confirmed by bootstrapping. External validation using data from a German cohort (Marburg, n = 774) revealed a receiver operating characteristics curve of 0.75 (95% confidence interval, 0.72; 0.81) with a sensitivity of 85.6% and a specificity of 47.2%. CONCLUSIONS This score, based only on history and physical examination, is a complementary tool for ruling out coronary heart disease in primary care patients complaining of chest pain.
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Affiliation(s)
- Baris Gencer
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland.
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