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Carollo C, Evola S, Sorce A, Cirafici E, Bennici M, Mulè G, Geraci G. Mission and One-Year Experience of a Kidney-Heart Outpatient Service: A Patient-Centered Management Model. J Clin Med 2025; 14:2102. [PMID: 40142910 PMCID: PMC11942838 DOI: 10.3390/jcm14062102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2025] [Revised: 03/10/2025] [Accepted: 03/14/2025] [Indexed: 03/28/2025] Open
Abstract
Background: Cardiorenal Syndrome (CRS) represents a growing global health challenge due to the increasing prevalence of coexisting kidney and heart disease. The complex pathophysiology of CRS demands an integrated, multidisciplinary approach involving both nephrology and cardiology. However, specialized care models remain limited, leading to fragmented management and suboptimal outcomes. Methods: A Kidney-Heart Outpatient Service was established at "Paolo Giaccone" University Hospital in Palermo in May 2023 to provide coordinated, multidisciplinary care for non-hospitalized patients with CRS. The service involves structured patient assessments, including medical history, physical examinations, laboratory tests, imaging, and a collaborative therapeutic plan formulated by nephrologists and cardiologists. Preliminary patient data were collected and analysed to assess demographic characteristics, comorbidities, and clinical outcomes. Results: Among the first 115 patients evaluated, most were male and over 70 years old. Hypertension (91%) and diabetes were the leading comorbidities, with CKD stage G3b being the most prevalent. Cardiovascular conditions such as atrial fibrillation (18%), prior myocardial infarction (17%), and heart failure (15%) were frequently observed. Three patient deaths occurred, and one progressed to hemodialysis. Conclusions: The Kidney-Heart Outpatient Service represents a novel, patient-centered model for CRS management, aiming to improve clinical outcomes and reduce hospital admissions through multidisciplinary collaboration. Longitudinal follow-up and expanded data collection are essential to validate the long-term efficacy of this approach and refine management strategies for CRS patients. Ongoing research efforts will focus on tracking patient outcomes over extended periods, optimizing therapeutic strategies, and further integrating nephrology and cardiology training. The goal is to establish a sustainable and scalable framework for CRS management that enhances patient care and reduces the healthcare burden.
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Affiliation(s)
- Caterina Carollo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) “G. D’Alessandro”, University of Palermo, 90133 Palermo, Italy (E.C.); (M.B.); (G.M.)
| | - Salvatore Evola
- Catheterization Laboratory, Department of Medicine and Cardiology, Azienda Ospedaliera Universitaria Policlinico “P. Giaccone”, 90127 Palermo, Italy;
| | - Alessandra Sorce
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) “G. D’Alessandro”, University of Palermo, 90133 Palermo, Italy (E.C.); (M.B.); (G.M.)
| | - Emanuele Cirafici
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) “G. D’Alessandro”, University of Palermo, 90133 Palermo, Italy (E.C.); (M.B.); (G.M.)
| | - Miriam Bennici
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) “G. D’Alessandro”, University of Palermo, 90133 Palermo, Italy (E.C.); (M.B.); (G.M.)
| | - Giuseppe Mulè
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) “G. D’Alessandro”, University of Palermo, 90133 Palermo, Italy (E.C.); (M.B.); (G.M.)
| | - Giulio Geraci
- Department of Medicine and Surgery, “Kore” University of Enna, 94100 Enna, Italy;
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Krimmel-Morrison JD, Watsjold BK, Berger GN, Bowen JL, Ilgen JS. 'Walking together': How relationships shape physicians' clinical reasoning. MEDICAL EDUCATION 2024; 58:961-969. [PMID: 38525645 DOI: 10.1111/medu.15377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning. METHODS Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest. RESULTS The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts. CONCLUSION Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.
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Affiliation(s)
| | - Bjorn K Watsjold
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Gabrielle N Berger
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Judith L Bowen
- Department of Medical Education and Clinical Sciences, Washington State University Elson S. Floyd School of Medicine, Spokane, Washington, USA
| | - Jonathan S Ilgen
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, USA
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Banton A, Vogel S, Lee-Treweek G. Making sense of cranial osteopathy: An interpretative phenomenological analysis. INT J OSTEOPATH MED 2023; 50:100673. [DOI: 10.1016/j.ijosm.2023.100673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Ismail F, Pretorius M, Peterson C, Yelverton C. The prevalence of chiropractic-related terminology on South African chiropractors' webpages: a cross-sectional study. Chiropr Man Therap 2023; 31:11. [PMID: 37013658 PMCID: PMC10071643 DOI: 10.1186/s12998-023-00483-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Effective communication is imperative for successful interprofessional collaborative interactions that augment both patient-centred and evidence based care. Inquiry into the prevalence of chiropractic-related terminology on South African chiropractor's webpages has not been explored to date. The implications of such analysis could indicate the professions' ability to effectively communicate in interdisciplinary settings. METHOD From 1 to 15 June 2020, Google search was used to identify the webpages (excluding social media accounts) of South African private practice chiropractors registered with the Allied Health Professions Council of South Africa (AHPCSA). Webpages were word-searched for eight chiropractic terms with context: subluxation; manipulate(-ion); adjust(-ing/-ment); holism(-tic); alignment; vital(-ism/-istic); wellness; and innate intelligence. Data collected was transferred to an Excel spreadsheet. Accuracy of information was verified by the researchers through a process of double checking. The number of instances each term was used, and certain socio-demographic data were recorded. Descriptive statistics and bivariate analyses were used to summarise and analyse the data. RESULTS Among 884 AHPCSA-registered South African chiropractors, 336 webpages were identified and analysed. From 1 to 15 June 2020, the most commonly found terms on 336 South African chiropractic webpages were 'adjust(-ing/-ment)', 'manipulate/manipulation', and 'wellness', with prevalence estimates of 64.1% (95% confidence interval [CI], 59.0% to 69.2%), 51.8% (95% CI, 46.5% to 57.1%), and 33.0% (95% CI, 28.2% to 38.2%), respectively. The least commonly found terms were 'innate intelligence' and 'vital(-ism/-istic)', with prevalence estimates of 0.60% (95% CI, 0.16% to 2.1%) and 0.30% (95% CI, 0.05% to 1.7%), respectively. Manipulate(-ion) was used more by male chiropractors (p = 0.015). The longer a chiropractor was in practice the more likely they were to use profession-specific terms (p = 0.025). The most frequently occurring combination of terms were adjust(-ing/-ment) and manipulate(-ion), found in 38 out of 336 webpages (11.3%; 95% CI, 8.4% to 15.1%). CONCLUSION The use of chiropractic-related terminology on South African chiropractic webpages was common, with the prevalence of term use varying by type of terms, by gender of the chiropractor, and by clinical practice experience. Better understanding of the effects of chiropractic terminology use on interprofessional and patient interactions and communication is warranted.
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Affiliation(s)
- F Ismail
- Department of Chiropractic, Faculty of Health Sciences, University of Johannesburg, Beit Street, Doornfontein, South Africa.
| | - M Pretorius
- Department of Chiropractic, Faculty of Health Sciences, University of Johannesburg, Beit Street, Doornfontein, South Africa
| | - C Peterson
- Department of Chiropractic, Faculty of Health Sciences, University of Johannesburg, Beit Street, Doornfontein, South Africa
| | - C Yelverton
- Department of Chiropractic, Faculty of Health Sciences, University of Johannesburg, Beit Street, Doornfontein, South Africa
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Bacharaki D, Petrakis I, Stylianou K. Redefying the therapeutic strategies against cardiorenal morbidity and mortality: Patient phenotypes. World J Cardiol 2023; 15:76-83. [PMID: 37033683 PMCID: PMC10074996 DOI: 10.4330/wjc.v15.i3.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/31/2022] [Accepted: 02/22/2023] [Indexed: 03/21/2023] Open
Abstract
Chronic kidney disease (CKD) patients face an unacceptably high morbidity and mortality, mainly from cardiovascular diseases. Diabetes mellitus, arterial hypertension and dyslipidemia are highly prevalent in CKD patients. Established therapeutic protocols for the treatment of diabetes mellitus, arterial hypertension, and dyslipidemia are not as effective in CKD patients as in the general population. The role of non-traditional risk factors (RF) has gained interest in the last decades. These entail the deranged clinical spectrum of secondary hyperparathyroidism involving vascular and valvular calcification, under the term "CKD-mineral and bone disorder" (CKD-MBD), uremia per se, inflammation and oxidative stress. Each one of these non-traditional RF have been addressed in various study designs, but the results do not exhibit any applied clinical benefit for CKD-patients. The "crusade" against cardiorenal morbidity and mortality in CKD-patients is in some instances, derailed. We propose a therapeutic paradigm advancing from isolated treatment targets, as practiced today, to precision medicine involving patient phenotypes with distinct underlying pathophysiology. In this regard we propose two steps, based on current stratification management of corona virus disease-19 and sepsis. First, select patients who are expected to have a high mortality, i.e., a prognostic enrichment. Second, select patients who are likely to respond to a specific therapy, i.e., a predictive enrichment.
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Affiliation(s)
- Dimitra Bacharaki
- Nephrology Unit, 2 Department of Internal Medicine, Attikon University Hospital, Chaidari 12462, Greece.
| | - Ioannis Petrakis
- Department of Nephrology, Heraklion University Hospital, University of Crete, Heraklion 71500, Greece
| | - Kostas Stylianou
- Department of Nephrology, Heraklion University Hospital, University of Crete, Heraklion 71500, Greece
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Moleman M, Jerak‐Zuiderent S, van de Bovenkamp H, Bal R, Zuiderent‐Jerak T. Evidence-basing for quality improvement; bringing clinical practice guidelines closer to their promise of improving care practices. J Eval Clin Pract 2022; 28:1003-1026. [PMID: 35089625 PMCID: PMC9787549 DOI: 10.1111/jep.13659] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/21/2021] [Accepted: 01/03/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) have become central to efforts to change clinical practice and improve the quality of health care. Despite growing attention for rigorous development methodologies, it remains unclear what contribution CPGs make to quality improvement. AIM This mixed methods study examines guideline quality in relation to the availability of certain types of evidence and reflects on the implications of CPGs' promise to improve the quality of care practices. METHODS The quality of 62 CPGs was assessed with the Appraisal of Guidelines, Research, and Evaluation (AGREE) instrument. Findings were discussed in 19 follow-up interviews to examine how different quality aspects were considered during development. RESULTS The AGREE assessment showed that while some quality criteria were met, CPGs have limited coverage of domains such as stakeholder involvement and applicability, which generally lack a 'strong' evidence base (e.g., randomized controlled trials [RCT]). Qualitative findings uncovered barriers that impede the consolidation of evidence-based guideline development and quality improvement including guideline scoping based on the patient-intervention-comparison-outcome (PICO) question format and a lack of clinical experts involved in evidence appraisal. Developers used workarounds to include quality considerations that lack a strong base of RCT evidence, which often ended up in separate documents or appendices. CONCLUSION Findings suggest that CPGs mostly fail to integrate different epistemologies needed to inform the quality improvement of clinical practice. To bring CPGs closer to their promise, guideline scoping should maintain a focus on the most pertinent quality issues that point developers toward the most fitting knowledge for the question at hand, stretching beyond the PICO format. To address questions that lack a strong evidence base, developers actually need to appeal to other sources of knowledge, such as quality improvement, expert opinion, and best practices. Further research is needed to develop methods for the robust inclusion of other types of knowledge.
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Affiliation(s)
- Marjolein Moleman
- Faculty of Science, Athena InstituteVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Sonja Jerak‐Zuiderent
- Department of Ethics, Law and HumanitiesAmsterdam University Medical Centre (Location AMC)AmsterdamThe Netherlands
| | | | - Roland Bal
- Institute of Health Policy & ManagementErasmus University RotterdamRotterdamThe Netherlands
| | - Teun Zuiderent‐Jerak
- Faculty of Science, Athena InstituteVrije Universiteit AmsterdamAmsterdamThe Netherlands
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Karlin J, Hodge CC. Intimacy, Anonymity, and "Care with Nothing in the Way" on an Abortion Hotline. Cult Med Psychiatry 2022:10.1007/s11013-022-09810-4. [PMID: 36441388 PMCID: PMC9707088 DOI: 10.1007/s11013-022-09810-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 11/30/2022]
Abstract
This essay is an ethnographic account of a volunteer, anonymous hotline of physicians and advanced practice providers who offer medical advice and guidance to those who are taking medications on their own to end their pregnancies. Attending to the phenomenology of caring on the Hotline reveals a new form of medical expertise at play, which we call "care with nothing in the way." By operating outside the State's scrutiny of abortion provision, the Hotline offers its volunteers a way to practice abortion care that aligns with their professional and political commitments and that distances them from the direct harm they see caused by the political, financial, and bureaucratic constraints of their clinical work. By delineating the structure of this new regime of care, these providers call into question the notion of the "good doctor." They radically re-frame widely shared assumptions about the tenets of the ideal patient-doctor relationship and engender a new form of intimacy-one based, ironically, out of anonymity and not the familiarity that is often idealized in the caregiving relationship. We suggest the implications of "care with nothing in the way" are urgent, not only in the context of increasing hostility to abortion rights, but also for a culture of medicine plagued by physician burnout.
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Affiliation(s)
- Jennifer Karlin
- Department of Family and Community Medicine, University of California, 4860 Y Street, Suite 2320, DavisSacramento, CA 95817 USA
| | - Caroline C. Hodge
- University of California, San Francisco School of Medicine, Department of Anthropology, University of Pennsylvania, 3260 South Street, Philadelphia, PA 19104 USA
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Lebert R, Noy M, Purves E, Tibbett J. Massage Therapy: A Person-Centred Approach to Chronic Pain. Int J Ther Massage Bodywork 2022; 15:27-34. [PMID: 36061225 PMCID: PMC9401086 DOI: 10.3822/ijtmb.v15i3.713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Person-centred care is an emergent movement within evidence-based medicine that has the potential to transform the health care system. Person-centred care is a collaborative approach in which health care professionals partner with patients to co-design and deliver personalized care with a focus on physical comfort, emotional well-being, and patient empowerment. By embracing person-centred care through two-way communication, patient engagement, and self-management strategies, massage therapists have the potential to further reduce suffering associated with chronic pain in our society.
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Affiliation(s)
- Richard Lebert
- The School of Health Science, Community Services and Creative Design, Lambton College, Sarnia, ON, Canada
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Toward a Clinically Reliable Class II Resin Composite Restoration: A Cross-Sectional Study into the Current Clinical Practice among Dentists in Saudi Arabia. Int J Dent 2022; 2022:2691376. [PMID: 35959095 PMCID: PMC9363216 DOI: 10.1155/2022/2691376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 07/11/2022] [Indexed: 12/03/2022] Open
Abstract
Objective The aim of this study was to evaluate the current clinical practice of general dentists in Saudi Arabia in restoring class II cavities using direct resin composites and to set evidence-based practice recommendations of concern. Methods An online survey formed of 20 questions and classified into four domains was developed. 500 dentists in 5 Saudi provinces were invited to join the survey anonymously and voluntarily using poster announcements and e-mail invitations. Descriptive statistics were used to analyze participants' responses. Results 343 responses were received. Dentists in Saudi Arabia vary in their clinical practices and techniques of insertion of resin composite in class II cavities. 67% of participants use cotton rolls for isolating the field while 32% use rubber dam isolation. 33% and 28% of respondents use circumferential matrix (Tofflemire) and AutoMatrix, respectively. Fracture, followed by recurrent caries and open proximal contacts, was the received main reason of failure of class II direct resin composite restorations. Conclusion Diversity of class II resin composite practices exists among dentists in Saudi Arabia. For ensuring optimum quality outcomes and high standards of restorative dentistry healthcare, several dentists in Saudi Arabia need to reconsider their clinical practice and modify their clinical procedures of direct class II resin composites. Several evidence-based practice guidelines are recommended to dentists in this article to improve their practice and enhance the clinical reliability and longevity of class II direct resin composite restorations.
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Martyushev-Poklad A, Yankevich D, Petrova M. Improving the Effectiveness of Healthcare: Diagnosis-Centered Care Vs. Person-Centered Health Promotion, a Long Forgotten New Model. Front Public Health 2022; 10:819096. [PMID: 35651862 PMCID: PMC9149093 DOI: 10.3389/fpubh.2022.819096] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 04/12/2022] [Indexed: 11/29/2022] Open
Abstract
Performance of healthcare can be measured as its ability to restore and preserve health with acceptable costs for the society. Under the current prevalence of chronic disease, medical care (the major content of healthcare) underperforms in all key indicators: clinical effectiveness, benefit/risk ratio of interventions, cost/benefit ratio, and general population health. In Russia key performance indicators (KPI) of healthcare do not allow effective decision-making; a similar situation is seen worldwide: most KPIs are either focused on the process (not results) of medical care, or depend on efforts out of control of healthcare decision-makers. The key root factors limiting clinical effectiveness and cost-effectiveness of healthcare are reactive diagnosis-centered organizational model of care and the underlying biomedical paradigm, generally inadequate in chronic diseases. They make healthcare intervene too late, use less effective prevention and treatment instruments, and be in a state of resource scarcity. In Russia there is also a lack of interdisciplinary and interagency cooperation essential for health preservation and promotion. Performance of healthcare system in overcoming the chronic disease epidemic can be improved through supplementing the current ‘reactive’ organizational model with preventive person-centered model based on the biopsychosocial paradigm. Enabling patients for early lifestyle-based interventions, the core P4 medicine approach, should prevail in managing chronic disease. Communication and information technologies should allow fast scaling up of the best person-centered practices.
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Wake E, Walters K, Winearls J, Marshall AP. Implementing and sustaining Point of Care ROTEM® into a trauma activation protocol for the management of patients with traumatic injury: A mixed-methods study. Aust Crit Care 2022; 36:336-344. [PMID: 35525809 DOI: 10.1016/j.aucc.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Up to 40% of patients with traumatic injury experience critical bleeding, many requiring transfusion of blood products. International transfusion guidelines recommend the use of viscoelastic testing to guide blood product replacement. We implemented a Point of Care ROTEM® blood test for trauma patients who present and initiate a trauma activation. OBJECTIVES The aim of this study was to undertake an evaluation of the implementation data to identify factors which helped and hindered this new practice. METHODS A sequential mixed-methods design was conducted to evaluate intervention implementation. The intervention was designed with interprofessional collaboration and incorporated education and skills training supplemented with a decision aide. Patients aged ≥ 18 years who met the trauma activation criteria were included. Data collection occurred throughout the 21-month implementation period inclusive of initial roll out, maintenance and sustainability and include the number of ROTEM® blood tests taken and clinical characteristics of patients. Individual interviews were conducted with health professionals with experience of the intervention after the implementation period was complete. RESULTS A total of 1570 eligible patients were included. The number of patients who had a ROTEM® blood test taken increased over time to 63%. The proportion of patients having a ROTEM® blood test obtained was higher for major trauma patients (n=162, 66.9%) who were admitted to the Intensive Care Unit. Regression analysis found trauma service presence on arrival and the sustainability phase of implementation increased the likelihood of having a ROTEM® taken. Qualitative data suggest that a more tailored approach to intervention implementation would assist with adoption. CONCLUSION Implementation of new practice requires careful planning and should be undertaken with input from end-users. Continuous evaluation is necessary to support ongoing implementation and sustainability. To ensure effective implementation occurs, complex interventions need to be made workable and integrated in everyday health care practice.
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Affiliation(s)
- Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, Queensland, Australia; School of Medicine, Griffith University, Gold Coast, Australia.
| | - Kerin Walters
- Intensive Care Unit, Gold Coast University Hospital, Queensland, Australia
| | - James Winearls
- Intensive Care Unit, Gold Coast University Hospital, Queensland, Australia; Senior Lecturer, University of Queensland, Australia
| | - Andrea P Marshall
- Nursing, Midwifery Education and Research Unit, Gold Coast University Hospital, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Queensland, Australia
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Russell G. Have we forgotten the moral justification for patient-centred care? BMJ Qual Saf 2021; 31:172-174. [PMID: 34301849 DOI: 10.1136/bmjqs-2020-012565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Grant Russell
- School of Primary Health Care, Monash University, Melbourne, Victoria, Australia
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Engle RL, Mohr DC, Holmes SK, Seibert MN, Afable M, Leyson J, Meterko M. Evidence-based practice and patient-centered care: Doing both well. Health Care Manage Rev 2021; 46:174-184. [PMID: 31233424 PMCID: PMC8162222 DOI: 10.1097/hmr.0000000000000254] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Health care organizations increasingly strive to deliver care that is both evidence based and patient centered. Although often complementary, fundamental contradictions may exist between these goals, and the organizational culture and infrastructure necessary to be successful in one domain may inherently diminish performance in the other. PURPOSE We assessed the relationship between evidence-based practice (EBP) and patient-centered care (PCC) by seeking to identify specific behavioral and process mechanisms, along with organizational characteristics that distinguish medical centers that are able to provide inpatient care that is both evidence based and patient centered from those where performance is either mixed or low in both domains. METHODOLOGY/APPROACH We analyzed interview data from 142 employees at 12 Veterans Affairs Medical Centers selected based on EBP and PCC performance (high, low, or mixed) using a priori constructs consistent with organizational literature, as well as emergent themes. RESULTS We confirmed that tensions may arise when attempting to deliver both EBP and PCC and found unique characteristics of organizations that do both well. High-performing sites exhibited organizational cultures of empowerment where both EBP and PCC expectations were emphasized; provided formal and informal institutional supports and structures with regard to PCC and EBP; and fostered multidisciplinary, multidirectional approaches to care and communication that facilitated delivery of both EBP and PCC. CONCLUSIONS AND PRACTICE IMPLICATIONS Organizations that excel in providing both EBP and PCC exhibit unique characteristics and processes. Recognizing that some characteristics such as culture are difficult to change, these findings nonetheless highlight areas that could be enhanced by medical centers striving to deliver care that is both evidence based and patient centered.
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Bacharaki D, Diamandopoulos A. Emperor's syndrome in the COVID-19 era: Time for patient-centered nephrology? World J Nephrol 2021; 10:1-7. [PMID: 33552939 PMCID: PMC7829681 DOI: 10.5527/wjn.v10.i1.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/04/2020] [Accepted: 11/11/2020] [Indexed: 02/06/2023] Open
Abstract
The coronavirus disease-19 (COVID-19) pandemic has been a wake-up call in which has forced us to react worldwide. Health policies and practices have attracted particular attention in terms of human and financial cost. Before COVID-19, chronic kidney disease was already considered a risk multiplier in patients with diabetes and hypertension, the two now being the major risk factors for COVID-19 infection and adverse outcome. In contrast to the urgent need for action, the nephrology field is considered to be in a state of stagnation regarding the management of chronic kidney disease patients who still experience unacceptably high morbidity and mortality. Ironically and paradoxically in a field lacking robust clinical trials, clinical practice is driven by guidelines-based medicine on weak evidence. The Emperor's syndrome, referring to Hans Christian Andersen's fairy tale, has been described in medicine as voluntary blindness to an obvious truth, being a weak evidence-based therapeutic intervention or weak health care. A promising positive example of improving heart and kidney outcomes is the emerging treatment with sodium-glucose cotransporter 2 inhibitors. COVID-19 could boost actions for patient-centered care as a positive shift in nephrology care.
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Affiliation(s)
- Dimitra Bacharaki
- Department of Nephrology, Attikon University Hospital, Chaidari 12462, Greece
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Yorganci E, Evans CJ, Johnson H, Barclay S, Murtagh FE, Yi D, Gao W, Pickles A, Koffman J. Understanding usual care in randomised controlled trials of complex interventions: A multi-method approach. Palliat Med 2020; 34:667-679. [PMID: 32081088 PMCID: PMC7238505 DOI: 10.1177/0269216320905064] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Evaluations of complex interventions compared to usual care provided in palliative care are increasing. Not describing usual care may affect the interpretation of an intervention's effectiveness, yet how it can be described remains unclear. AIM To demonstrate the feasibility of using multi-methods to describe usual care provided in randomised controlled trials (RCTs) of complex interventions, shown within a feasibility cluster RCT. DESIGN Multi-method approach comprising usual care questionnaires, baseline case note review and focus groups with ward staff completed at study end. Thematic analysis of qualitative data, descriptive statistics of quantitative data, followed by methodological triangulation to appraise approach in relation to study aim. SETTING/PARTICIPANTS Four general medical wards chosen from UK hospitals. Purposive sampling of healthcare professionals for usual care questionnaires, and focus groups. Review of 20 patients' notes from each ward who died during admission or within 100 days of discharge. RESULTS Twenty-three usual care questionnaires at baseline, two focus groups comprising 20 healthcare professionals and 80 case note reviews. Triangulation of findings resulted in understanding the usual care provided to the targeted population in terms of context, structures, processes and outcomes for patients, families and healthcare professionals. Usual care was described, highlighting (1) similarities and embedded practices, (2) heterogeneity and (3) subtle changes in care during the trial within and across sites. CONCLUSIONS We provide a feasible approach to defining usual care that can be practically adopted in different settings. Understanding usual care enhances the reliability of tested complex interventions, and informs research and policy priorities.
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Affiliation(s)
- Emel Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
| | - Halle Johnson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fliss Em Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Andrew Pickles
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jonathan Koffman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Berg K, Askim T, Rise MB. What do speech-language pathologists describe as most important when trying to achieve client participation during aphasia rehabilitation? A qualitative focus group interview study. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 21:493-503. [PMID: 29252012 DOI: 10.1080/17549507.2017.1413134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 10/30/2017] [Accepted: 11/30/2017] [Indexed: 06/07/2023]
Abstract
Purpose: The aim of this study was to investigate what speech-language pathologists describe as most important when trying to achieve client-oriented participation during aphasia rehabilitation. Method: A qualitative study including semi-structured focus group interviews with 11 speech-language pathologists. Interviews were analysed with the use of systematic text condensation. Result: Four main themes emerged from the analysis. (1) It is important to take the vulnerability of the client group into account. (2) It is important to address the client's process of realisation by navigating around unrealistic wishes and goals. (3) It is challenging to involve clients when the evidence-base for clinical practice is limited. (4) It is crucial to make therapy meaningful to the client. Conclusion: This study showed that speech-language pathologists perceived prediction of a clinical course in aphasia rehabilitation as challenging due to the vulnerable client group and the perceived need to guide the clients through the rehabilitation process. They talked about how unrealistic client goals, and the lack of a solid evidence-base to guide their clinical practice, made collaborative goal setting and treatment planning challenging. Due to these barriers, the speech-language pathologists struggled to achieve client participation, and thereby aphasia rehabilitation could not be described as fully client-oriented.
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Affiliation(s)
- Karianne Berg
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU, Norwegian University of Science and Technology , Trondheim , Norway and
| | - Torunn Askim
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU, Norwegian University of Science and Technology , Trondheim , Norway and
| | - Marit By Rise
- Department of Mental Health, Faculty of Medicine and Health Science, NTNU, Norwegian University of Science and Technology , Trondheim , Norway
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Stuber KJ, Langweiler M, Mior S, McCarthy PW. A pilot study assessing patient-centred care in patients with chronic health conditions attending chiropractic practice. Complement Ther Med 2018; 39:1-7. [PMID: 30012379 DOI: 10.1016/j.ctim.2018.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The primary aim of this pilot study was to determine the feasibility of conducting a mixed- methods study assessing the extent patients with chronic health conditions perceive chiropractic care to be patient-centred. DESIGN A sequential mixed methods feasibility study with a quantitative priority. SETTING Two private chiropractic clinics in Calgary, Alberta, Canada. MAIN OUTCOME MEASURES Feasibility outcomes included pilot study participation, consent and completion rates. Demographic and health information and a modified version of the Patient Assessment of Chronic Illness Care (PACIC). RESULTS Over three weeks, 90 participants were recruited, 86 enrolled, and 78 provided complete data, with only one who commented on the clarity of paperwork. Included participants were on average 47.1 years of age and 60.3% were female. They had an average of 1.8 chronic conditions with 60% having chronic spinal pain. They reported seeing an average of 2.9 other health professionals for their chronic health condition and averaged 12.9 chiropractic visits in the past year. The average overall modified PACIC score was 3.29 on a 5-point scale. Higher scores were seen on the 'patient activation', 'delivery system design/decision support', and 'problem solving/contextual' subscales, with lower scores seen on the 'goal-setting/tailoring' and 'follow-up/coordination' subscales. Interview data generally supported those findings. CONCLUSIONS The pilot study results support the feasibility of the methods for a subsequent large-scale study. These preliminary results suggest that the degree of patient-centredness compares favourably to similar studies in primary medical care.
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Affiliation(s)
- Kent J Stuber
- Division of Graduate Education and Research, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada; Faculty of Life Sciences and Education, University of South Wales, Treforest, Wales, UK.
| | - Mark Langweiler
- Faculty of Life Sciences and Education, University of South Wales, Treforest, Wales, UK.
| | - Silvano Mior
- Division of Graduate Education and Research, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada.
| | - Peter W McCarthy
- Division of Graduate Education and Research, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario, M2H 3J1, Canada.
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Zolkipli-Cunningham Z, Xiao R, Stoddart A, McCormick EM, Holberts A, Burrill N, McCormack S, Williams L, Wang X, Thompson JLP, Falk MJ. Mitochondrial disease patient motivations and barriers to participate in clinical trials. PLoS One 2018; 13:e0197513. [PMID: 29771953 PMCID: PMC5957366 DOI: 10.1371/journal.pone.0197513] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 05/03/2018] [Indexed: 01/21/2023] Open
Abstract
Background Clinical treatment trials are increasingly being designed in primary mitochondrial disease (PMD), a phenotypically and genetically heterogeneous collection of inherited multi- system energy deficiency disorders that lack effective therapy. We sought to identify motivating factors and barriers to clinical trial participation in PMD. Methods A survey study was conducted in two independent mitochondrial disease subject cohorts. A discovery cohort invited subjects with well-defined biochemical or molecularly- confirmed PMD followed at a single medical center (CHOP, n = 30/67 (45%) respondents). A replication cohort included self-identified PMD subjects in the Rare Disease Clinical Research Network (RDCRN) national contact registry (n = 290/1119 (26%) respondents). Five-point Likert scale responses were analyzed using descriptive and quantitative statistics. Experienced and prioritized symptoms for trial participation, and patient attitudes toward detailed aspects of clinical trial drug features and study design. Results PMD subjects experienced an average of 16 symptoms. Muscle weakness, chronic fatigue, and exercise intolerance were the lead symptoms encouraging trial participation. Motivating trial design factors included a self-administered study drug; vitamin, antioxidant, natural or plant-derivative; pills; daily treatment; guaranteed treatment access during and after study; short travel distances; and late-stage (phase 3) participation. Relative trial participation barriers included a new study drug; discontinuation of current medications; disease progression; daily phlebotomy; and requiring participant payment. Treatment trial type or design preferences were not influenced by population age (pediatric versus adult), prior research trial experience, or disease severity. Conclusions These data are the first to convey clear PMD subject preferences and priorities to enable improved clinical treatment trial design that cuts across the complex diversity of disease. Partnering with rare disease patient communities is essential to effectively design robust clinical trials that engage patients and enable meaningful evaluation of emerging treatment interventions.
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Affiliation(s)
- Zarazuela Zolkipli-Cunningham
- Division of Neurology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Mitochondrial Medicine Frontier Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Rui Xiao
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Amy Stoddart
- Mitochondrial Medicine Frontier Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Arcadia University, Glenside, Pennsylvania, United States of America
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Elizabeth M. McCormick
- Mitochondrial Medicine Frontier Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Amy Holberts
- Rare Diseases Clinical Research Network, Health Informatics Institute, University of South Florida, Tampa, Florida, United States of America
| | - Natalie Burrill
- Mitochondrial Medicine Frontier Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | - Shana McCormack
- Mitochondrial Medicine Frontier Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Lauren Williams
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, New York, United States of America
| | - Xiaoyan Wang
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, New York, United States of America
| | - John L. P. Thompson
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, New York, United States of America
| | - Marni J. Falk
- Mitochondrial Medicine Frontier Program, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, New York, United States of America
- * E-mail:
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Shukor AR. An Alternative Paradigm for Evidence-Based Medicine: Revisiting Lawrence Weed, MD's Systems Approach. Perm J 2017; 21:16-147. [PMID: 28488985 PMCID: PMC5424594 DOI: 10.7812/tpp/16-147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Lawrence Weed, MD, is renowned for being the father of the Problem-Oriented Medical Record (POMR), the medical care standard for collecting, managing, and contextualizing patient data in medical records. What have been consistently overlooked are his teachings on knowledge coupling, which refers to matching patient data with associated medical knowledge. Together, the POMR standard and knowledge coupling are meant to form the basis of a systems approach that enables individualized evidence-based decision making within the context of multimorbidity and patient complexity.The POMR and knowledge coupling tools operationalize a problem-oriented model that reflects a sophisticated general systems theoretical approach to knowledge. This paradigm transcends reductionist approaches to knowledge by depicting how the meaning of specific entities (eg, disease constructs) and their associated probabilities can only be understood within their respective spatiotemporal and biopsychosocial relational contexts. Rigorous POMRs therefore require knowledge inputs from a network of interconnections among specific entities, which Dr Weed enabled through development of the Knowledge Net standard. The Knowledge Net's relational structure determines the applicability of knowledge within specific patient contexts. To enable the linkage of unique combinations of data in individual patient POMRs with existing medical knowledge structured in Knowledge Nets, Dr Weed developed the Knowledge Coupling standard.Dr Weed's standards for record keeping and knowledge coupling form the basis of a combinatorial approach to evidence-based medicine that fulfills Stange's call for a science of connectedness. Ensuing individualized processes of care become the dynamo powering a learning health care system that enables a co-construction of health premised on empowerment and intelligent human decision making, rather than promoting the artificial intelligence of tools. If the value of Engel's biopsychosocial model indeed relates to "guiding the parsimonious application of medical knowledge to the needs of each patient," Dr Weed's approach warrants serious consideration.
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Affiliation(s)
- Ali Rafik Shukor
- Doctoral Candidate in Social Medicine at the Academisch Medisch Centrum in Amsterdam, The Netherlands.
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