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A qualitative study on community pharmacists' decision-making process when making a diagnosis.

A qualitative study on community pharmacists' decision-making process when making a diagnosis.

J Eval Clin Pract. 2017 Oct 08;:

Authors: Sinopoulou V, Summerfield P, Rutter P

Abstract
RATIONALE, AIMS, AND OBJECTIVES: Self-care policies are increasingly directing patients to seek advice from community pharmacists. This means pharmacists need to have sound diagnostic decision-making skills to enable them to recognise a variety of conditions. The aim of this study was to investigate the process by which pharmacists manage patient signs and symptoms and to explore their use of decision-making for diagnostic purposes.
METHODS: Data were collected through semi-structured, face-to-face interviews with community pharmacists working in England, between August 2013 and November 2014. Pharmacists were asked to share their experiences on how they performed patient consultations, and more specifically how they would approach a hypothetical headache scenario. As part of the interview, their sources of knowledge and experience were also explored. Framework analysis was used to identify themes and subthemes.
RESULTS: Eight interviews were conducted with pharmacists who had a wide range of working practice, from 1 year through to 40 years of experience. The pharmacists' main motivations during consultations were product selection and risk minimisation. Their questioning approach and decision-making relied heavily on mnemonic methods. This led to poor quality information gathering-although pharmacists acknowledged they needed to "delve deeper" but were often unable to articulate how or why. Some pharmacists exhibited elements of clinical reasoning in their consultations, but this seemed, mostly, to be unconscious and subsequently applied inappropriately. Overall, pharmacists exhibited poor decision-making ability, and often decisions were based on personal belief and experiences rather than evidence.
CONCLUSIONS: Community pharmacists relied heavily on mnemonic methods to manage patients' signs and symptoms with diagnosis-based decision-making being seldom employed. These findings suggest practicing pharmacists should receive more diagnostic training.

PMID: 28990319 [PubMed - as supplied by publisher]




Psychometric validation of a new measurement instrument for time-oriented patient information in electronic medical records: A questionnaire survey of physicians.

Psychometric validation of a new measurement instrument for time-oriented patient information in electronic medical records: A questionnaire survey of physicians.

J Eval Clin Pract. 2017 Oct 08;:

Authors: Shibuya A, Misawa J, Maeda Y, Ichikawa R, Kamata M, Inoue R, Morimoto T, Nakayama M, Hishiki T, Kondo Y

Abstract
RATIONALE, AIMS, AND OBJECTIVES: Time is an important element in medical data. Physicians record and store information about patients' disease progress and treatment response in electronic medical records (EMRs). Because EMRs use timestamps, physicians can identify patterns over time regarding a patient's disease and treatment (eg, laboratory values and medications). However, analyses of physicians' use and satisfaction with EMRs have focused on functionality, storage, and system operation rather than the use of time-oriented information. This study aimed to understand physicians' needs regarding time-oriented patient information in EMRs in clinical practice.
METHODS: The reliability and validity of the items in the questionnaire were evaluated in 87 physicians at a national university hospital. Internal consistency was satisfactory (Cronbach alpha coefficient, 0.87).
RESULTS: Four dimensions were identified in exploratory factor analysis. Correlations between the 4 dimensions supported the construct validity of the items. Scores of time-oriented patients' medical history in the 4 dimensions showed a significant association with physician age. Based on confirmatory factor analysis, associations were significant and positive (P < .001). In terms of the needs of physicians regarding time-oriented patient information in EMRs, both time-oriented treatment results followed by time-oriented team information had significant positive associations.
CONCLUSION: Our study suggests that 4 specific time-oriented patient information factors in EMRs are needed by physicians. Exploring physicians' needs regarding patient-specific time-oriented information may provide a better understanding of the barriers facing the adoption and use of EMRs (eg, decision-making and practice safety concerns) and lead to better acceptance of EMRs in physicians' clinical practices.

PMID: 28990315 [PubMed - as supplied by publisher]




Female breast cancer management and survival: The experience of major public hospitals in South Australia over 3 decades-trends by age and in the elderly.

Female breast cancer management and survival: The experience of major public hospitals in South Australia over 3 decades-trends by age and in the elderly.

J Eval Clin Pract. 2017 Oct 08;:

Authors: Roder D, Farshid G, Kollias J, Koczwara B, Karapetis C, Adams J, Joshi R, Keefe D, Miller C, Powell K, Fusco K, Eckert M, Buckley E, Beckmann K, Price T

Abstract
BACKGROUND: Clinical registry data from major South Australian public hospitals were used to investigate trends in invasive breast-cancer treatment and survival by age.
METHODS: Disease-specific survival was calculated for the 1980 to 2013 diagnostic period using Kaplan-Meier product-limit estimates, with a censoring of live cases on December 31, 2014. Cox proportional hazards regression was used to examine differences in survival by age and tumour characteristic. First-round treatments following diagnosis were analysed, using multiple logistic regression to adjust for confounding.
RESULTS: Five-year survival increased from 75% in the 1980s to 87% in 2000 to 2013, consistent with national trends, and with increases occurring irrespective of age. There was an increased use of breast conserving surgery, radiotherapy, chemotherapy, and hormone treatments. Five-year survival was lower for women aged 80+ years, increasing from 65% in the 1980s to 74% in 2000 to 2013. Lower survival in these older women persisted after adjusting for TNM stage, other clinical variables, and diagnostic year, without evidence of a reduced disparity over time. Older women were less likely to have surgery, radiotherapy, and chemotherapy throughout 1980 to 2013. By comparison, their use of hormone therapy was elevated. The adjusted relative odds of mastectomy (as opposed to breast conserving surgery) were lower for the 80+ year age range.
CONCLUSIONS: Breast-cancer survival increases applied to all ages, including 80+ years, but poorer outcomes persisted in this older group and the gap did not reduce. A key question is whether the best trade-off now exists between optimally therapeutic cancer treatment and accommodations for frailty and co-morbidity in the aged, or whether opportunities exist for better trade-offs and better survival. Local registry data are important for describing local service activity and outcomes by age for local service providers, health administrations and consumer groups; monitoring disparities; and indicating effects of local initiatives.

PMID: 28990314 [PubMed - as supplied by publisher]




Physical activity interventions are delivered consistently across hospitalized older adults but multimorbidity is associated with poorer rehabilitation outcomes: A population-based cohort study.

Physical activity interventions are delivered consistently across hospitalized older adults but multimorbidity is associated with poorer rehabilitation outcomes: A population-based cohort study.

J Eval Clin Pract. 2017 Oct 08;:

Authors: Jones J, Jones GD, Thacker M, Faithfull S

Abstract
BACKGROUND: Older adults live with multimorbidity including frailty and cognitive impairment often requiring hospitalization. While physical activity interventions (PAIs) are a normal rehabilitative treatment, their clinical effect in hospitalized older adults is uncertain.
OBJECTIVE: To observe PAI dosing characteristics and determine their impact on clinical performance parameters.
DESIGN: A single-site prospective observational cohort study in an older persons' unit.
SUBJECTS: Seventy-five older persons' unit patients ≥65 years.
INTERVENTION: PAI; therapeutic contact between physiotherapy clinician and patient.
MEASUREMENTS: Parameters included changes in activities-of-daily-living (Barthel Index), handgrip strength, balance confidence, and gait velocity, measured between admission and discharge (episode). Dosing characteristics were PAI temporal initiation, frequency, and duration. Frailty/cognition status was dichotomized independently per participant yielding 4 subgroups: frail/nonfrail and cognitively-impaired/cognitively-unimpaired.
RESULTS: Median (interquartile range) PAI initiation occurred after 2 days (1-4), frequency was 0.4 PAIs per day (0.3-0.5), and PAI duration per episode was 3.75 hours (1.8-7.2). All clinical parameters improved significantly across episodes: grip strength median (interquartile range) change, 2.0 kg (0.0-2.3) (P < .01); Barthel Index, 5 (3-8) (P < .01); gait velocity, 0.06 m.∙s(-1) (0.06-0.16) (P < .01); and balance confidence, -3 (-6 to -1) (P < .01). Physical activity intervention dosing remained consistent within subgroups. While several moderate to large associations between amount of PAIs and change in clinical parameters were observed, most were within unimpaired subgroups.
CONCLUSIONS: PAI dosing is consistent. However, while clinical changes during hospital episodes are positive, more favourable responses to PAIs occur if patients are nonfrail/cognitively-unimpaired. Therefore, to deliver a personalized rehabilitation approach, adaptation of PAI dose based on patient presentation is desirable.

PMID: 28990265 [PubMed - as supplied by publisher]