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Recently, tablet-based devices have become significantly more utilized platforms for electronic medical record (EMR) systems. EMR is the digital counterpart of the medical doctor's office paper charts. EMR systems contain the medical and treatment histories of the patients in a unified practice. Nevertheless, statistics indicate that a considerable percentage of medical doctors are elderly, aged 60 and above. As using mobile handheld devices (including tablets) poses a well-recognized usability challenge for elderly users, the user interface (UI) usability of tablet-based EMR systems must be thoroughly assessed, considering the needs of elderly medical doctors. Accordingly, our objective is to address this need. Three expert evaluators implemented the heuristic evaluation (HE) approach to evaluate the UI usability of a commercial EMR system that is a tablet-based platform. Applying the HE approach helped identify usability problems that elderly medical doctors might encounter when utilizing a tablet-based EMR UI. In total, eight usability problems contributed to the seven heuristic violations discovered. [ABSTRACT FROM AUTHOR]

Jordanian healthcare institutes have launched several programs since 2009 to establish health information systems (HISs). Nowadays, the generic expectation is that the use of HIS resources is performed on daily basis among healthcare staff. However, there can be still a noticeable barrier due to a lack of knowledge if medical doctors do not receive proper training on existing HISs. Moreover, the lack of studies on this area hinders the clarity about the received versus the required training skills among medical doctors. To support this research initiative, survey data have been collected from specialized medical doctors who are currently affiliated with five Jordanian universities to assess their need for HIS training. The results also aim to explore the extent of medical doctors' use of HIS resources in Jordan. Moreover, they examine whether medical doctors require additional training on using HIS resources or not, as well as the main areas of required training programs. Specifically, this paper highlights the main topics that can be suitable subjects for enhanced training programs. The results show that most respondents use HISs in their daily clinical practices. However, most of them have not taken professional training on such systems. Hence, most of the respondents reported the need for additional training programs on several aspects of HIS resources. Moreover, based on the survey results, the most significant areas that require training are biomedical data analysis, artificial intelligence in medicine, health care management, and recent advances in electronic health records, respectively. Therefore, specialized medical doctors in Jordan need training on extracting useful and potential features of HISs. Education and training professionals in healthcare are recommended to establish training programs in Jordanian healthcare centers, which can further improve the quality of healthcare. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has highlighted the critical role of medical doctors in vaccine recommendation adherence. This study aimed to explore the factors influencing adherence to COVID-19 vaccine recommendations among Romanian medical doctors, one year into the vaccination campaign. We conducted a cross-sectional voluntary survey, and data from 94 physician respondents were analysed. We found that specialty, fear of adverse effects, and inflexible thinking were significant factors influencing vaccine recommendation adherence. General practitioners have higher adherence, while surgical specialists are more reluctant. Political and religious views don't associate with adherence to vaccine recommendations. These findings emphasize the importance of educational interventions to improve adherence and mitigate fear among medical doctors. [ABSTRACT FROM AUTHOR]

Introduction: The Swedish Register of Palliative Care (SRPC) is a national quality register that collects data about end-of-life care from healthcare providers that care for dying patients. Data are used for quality control and research. Data are mainly collected with an end-of-life questionnaire (ELQ), which is completed by healthcare staff after the death of a patient. A previous validity assessment of the ELQ showed insufficient validity in some items including symptom relief. The aim of this study was to examine the validity of the revised ELQ. Materials and methods: Data from 100 consecutive patients’ medical records at two specialised palliative care units were used to complete new ELQs, which were then compared to the ELQ registrations from the SRPC for the same patients. The level of agreement was calculated for each ELQ item. To account for the possibility of the agreement occurring by chance, Cohen’s kappa was calculated for suitable items. To examine the extent of registration mistakes when transferring the paper form to the web, the original paper versions of the ELQ filled out at the units were compared to data from the ELQs reported to the SRPC. Results: Level of agreement between ELQ registrations from the SRPC and the new ELQs based on the medical records varied between 0.55 and 1.00, where 24 items showed level of agreement above 0.80 and 9 items showed level of agreement below 0.80. Cohen’s kappa with 95% confidence intervals was calculated for 24 items. The kappa values showed that two items had poor agreement, four fair agreement, 11 moderate agreement, five good agreement and two very good agreement. The level of agreement varied between 0.93 and 1.00 when comparing the ELQ registrations in the SRPC and the paper forms. Conclusion: The revised ELQ contains more items with high levels of agreement between registrations in the SRPC and notes in the patients’ medical records when compared to the previous version. Validating issues around symptom assessment remains a challenge in our model of quality assessment. [ABSTRACT FROM AUTHOR]

We reveal the enigmatic origin of one of the earliest surviving botanical collections. The 16th-century Italian En Tibi herbarium is a large, luxurious book with c. 500 dried plants, made in the Renaissance scholarly circles that developed botany as a distinct discipline. Its Latin inscription, translated as “Here for you a smiling garden of everlasting flowers”, suggests that this herbarium was a gift for a patron of the emerging botanical science. We follow an integrative approach that includes a botanical similarity estimation of the En Tibi with contemporary herbaria (Aldrovandi, Cesalpino, “Cibo”, Merini, Estense) and analysis of the book’s watermark, paper, binding, handwriting, Latin inscription and the morphology and DNA of hairs mounted under specimens. Rejecting the previous origin hypothesis (Ferrara, 1542–1544), we show that the En Tibi was made in Bologna around 1558. We attribute the En Tibi herbarium to Francesco Petrollini, a neglected 16th-century botanist, to whom also belongs, as clarified herein, the controversial “Erbario Cibo” kept in Rome. The En Tibi was probably a work on commission for Petrollini, who provided the plant material for the book. Other people were apparently involved in the compilation and offering of this precious gift to a yet unknown person, possibly the Habsburg Emperor Ferdinand I. The En Tibi herbarium is a Renaissance masterpiece of art and science, representing the quest for truth in herbal medicine and botany. Our multidisciplinary approach can serve as a guideline for deciphering other anonymous herbaria, kept safely “hidden” in treasure rooms of universities, libraries and museums. [ABSTRACT FROM AUTHOR]

Considering the skills shortages in the South African health sector, this study explores the possibility of integrating foreign medical doctors into the under-staffed South African health sector. In achieving this aim, semi-structured interviews were conducted amongst 37 medical doctors, alongside three business entities who recruit skilled migrants. More so, textual analysis and review of audited documents in alignment with this papers theme are reviewed. The study emphasises that no assertive policies or stratagem have been enacted or devised by the South African government or non-governmental entities in integrating such foreign doctors. In furtherance to this, no comprehensive documentation of migrants’ competence has been considered at the port of entry by the Department of Home Affairs which, on its own, represents a missed opportunity. As an agendum to integrating foreign medical doctors regionally, nationally, or locally, the study advocates a comprehensive compilation of migrants’ skills, competence, and qualifications at the port of entries. Such useful data will not only be used for decisive policies but could also be used to integrate, relocate, or mix-match skilled migrants into the under-staffed South African health sector, or integrate them into regions across the globe where their services are needed. [ABSTRACT FROM AUTHOR]

Background: Due to the disease’s progressive nature, advance care planning (ACP) is recommended for people with early stage dementia. General practitioners (GPs) should initiate ACP because of their longstanding relationships with their patients and their early involvement with the disease, however ACP is seldom applied. Aim: To determine the barriers and facilitators faced by GPs related to ACP with people with dementia. Data sources: We systematically searched the relevant databases for papers published between January 1995 and December 2016, using the terms: primary healthcare, GP, dementia, and ACP. We conducted a systematic integrative review following Whittemore and Knafl’s method. Papers containing empirical data about GP barriers and/or facilitators regarding ACP for people with dementia were included. We evaluated quality using the Mixed-Method-Appraisal-Tool and analyzed data using qualitative content analysis. Results: Ten qualitative, five quantitative, and one mixed-method paper revealed four themes: timely initiation of ACP, stakeholder engagement, important aspects of ACP the conversation, and prerequisites for ACP. Important barriers were: uncertainty about the timing of ACP, how to plan for an uncertain future, lack of knowledge about dementia, difficulties assessing people with dementia’s decisional capacities, and changing preferences. Facilitators for ACP were: an early start when cognitive decline is still mild, inclusion of all stakeholders, and discussing social and medical issues aimed at maintaining normal life. Conclusion: Discussing future care is difficult due to uncertainties about the future and the decisional capacities of people with dementia. Based on the facilitators, we recommend that GPs use a timely and goal-oriented approach and involve all stakeholders. ACP discussions should focus on the ability of people with dementia to maintain normal daily function as well as on their quality of life, instead of end-of-life-discussions only. GPs need training to acquire knowledge and skills to timely initiate collaborative ACP discussions. [ABSTRACT FROM AUTHOR]

Objective: This paper reflected on the prevalence of hypertension and diabetes in Bangladesh, which is spreading rapidly in low-income countries. The rationale of constructing more health centers for addressing NCDs was assessed in this paper by determining the relationship between prevalence of NCDs, particularly hypertension and diabetes, and distance to health facilities. Methods: From BDHS (Bangladesh Health and Demographic Survey) 2011 data set, 7544 samples were analyzed to demonstrate association between Non-communicable diseases (NCD) and distance from respondents’ home to health facilities like hospitals, community clinics, pharmacies or doctors’ chambers, and community facilities like market, post office or cinema hall. Bivariate analysis was conducted between accessibility to health facilities and prevalence of the diseases. The causal relationship between the spatial effects and the prevalence of the diseases were analyzed by applying Generalized Linear Mixed Model (GLMM) was fitted. Results: Fitting linear mixed effect models, we found that hypertension and diabetes react differently with various spatial effects. Distance from home to hospital had significant effect (P < 0.001) on hypertension showing people living further from the facilities or town centers seemed to be less hypertensive, whereas diabetes showed no such affiliation. Conclusion: Higher prevalence of diabetes (40.9%) over hypertension (26.5%) in people aging 35 or higher, have appeared to have caused the difference, which concluded that each non-communicable disease should be dealt to its own merit for policy making instead considering as a group of diseases. [ABSTRACT FROM AUTHOR]

Objectives: The main purpose of this paper was to model the process by which patients enter the ED, are seen by physicians, and discharged from the Emergency Department at Nationwide Children’s Hospital, as well as identify modifiable factors that are associated with ED lengths of stay through use of multistate modeling. Methods: In this study, 75,591 patients admitted to the ED from March 1st, 2016 to February 28th, 2017 were analyzed using a multistate model of the ED process. Cox proportional hazards models with transition-specific covariates were used to model each transition in the multistate model and the Aalen-Johansen estimator was used to obtain transition probabilities and state occupation probabilities in the ED process. Results: Acuity level, season, time of day and number of ED physicians had significant and varying associations with the six transitions in the multistate model. Race and ethnicity were significantly associated with transition to left without being seen, but not with the other transitions. Conversely, age and gender were significantly associated with registration to room and subsequent transitions in the model, though the magnitude of association was not strong. Conclusions: The multistate model presented in this paper decomposes the overall ED length of stay into constituent transitions for modeling covariate-specific effects on each transition. This allows physicians to understand the ED process and identify which potentially modifiable covariates would have the greatest impact on reducing the waiting times in each state in the model. [ABSTRACT FROM AUTHOR]

Objectives: This paper presents a geographic information system (GIS)-based proximal area method and gravity method for identifying areas with physician shortages. The innovation of this paper is that it uses the appropriate methods to discover each type of health resource and then integrates all these methods to assess spatial access to health resources using population distribution data. In this way, spatial access to health resources for an entire city can be visualized in one neat package, which can help health policy makers quickly comprehend realistic distributions of health resources at a macro level. Methods: First, classify health resources according to the trade areas of the patients they serve. Second, apply an appropriate method to each different type of health resource to measure spatial access to those resources. Third, integrate all types of access using population distribution data. Results: In case study of Shanghai with the fusion method, areas with physician shortages are located primarily in suburban districts, especially in district junction areas. The result suggests that the government of Shanghai should pay more attention to these areas by investing in new or relocating existing health resources. Conclusion: The fusion method is demonstrated to be more accurate and practicable than using a single method to assess spatial access to health resources. [ABSTRACT FROM AUTHOR]

Background: Prognostic accuracy in palliative care is valued by patients, carers, and healthcare professionals. Previous reviews suggest clinicians are inaccurate at survival estimates, but have only reported the accuracy of estimates on patients with a cancer diagnosis. Objectives: To examine the accuracy of clinicians’ estimates of survival and to determine if any clinical profession is better at doing so than another. Data Sources: MEDLINE, Embase, CINAHL, and the Cochrane Database of Systematic Reviews and Trials. All databases were searched from the start of the database up to June 2015. Reference lists of eligible articles were also checked. Eligibility Criteria: Inclusion criteria: patients over 18, palliative population and setting, quantifiable estimate based on real patients, full publication written in English. Exclusion criteria: if the estimate was following an intervention, such as surgery, or the patient was artificially ventilated or in intensive care. Study Appraisal and Synthesis Methods: A quality assessment was completed with the QUIPS tool. Data on the reported accuracy of estimates and information about the clinicians were extracted. Studies were grouped by type of estimate: categorical (the clinician had a predetermined list of outcomes to choose from), continuous (open-ended estimate), or probabilistic (likelihood of surviving a particular time frame). Results: 4,642 records were identified; 42 studies fully met the review criteria. Wide variation was shown with categorical estimates (range 23% to 78%) and continuous estimates ranged between an underestimate of 86 days to an overestimate of 93 days. The four papers which used probabilistic estimates tended to show greater accuracy (c-statistics of 0.74–0.78). Information available about the clinicians providing the estimates was limited. Overall, there was no clear “expert” subgroup of clinicians identified. Limitations: High heterogeneity limited the analyses possible and prevented an overall accuracy being reported. Data were extracted using a standardised tool, by one reviewer, which could have introduced bias. Devising search terms for prognostic studies is challenging. Every attempt was made to devise search terms that were sufficiently sensitive to detect all prognostic studies; however, it remains possible that some studies were not identified. Conclusion: Studies of prognostic accuracy in palliative care are heterogeneous, but the evidence suggests that clinicians’ predictions are frequently inaccurate. No sub-group of clinicians was consistently shown to be more accurate than any other. Implications of Key Findings: Further research is needed to understand how clinical predictions are formulated and how their accuracy can be improved. [ABSTRACT FROM AUTHOR]

Background: Partnerships in global health and development governance have been firmly established as a tool to achieve effective outcomes. Botswana implements Safe Male Circumcision (SMC) for HIV prevention through a North-South partnership comprising the local Ministry of Health, US Centers for Disease Control and Prevention (funded by PEPFAR) and Africa Comprehensive HIV/AIDS Partnership (funded by the Bill and Melinda Gates Foundation). The SMC partnership experienced significant antagony and the aim of this paper is to illuminate the actions and processes in the SMC program that contributed to that antagony. Methods: Methods used to gather data include observation of the partners’ planning and strategic meeting in 2012, in-depth interviews with lead officers at national level, focus group discussions with district officers and implementers, younger male officers and old community members as recipients of the service. Results: The findings reveal that the partnership experienced antagony during operational processes and as the ultimate outcome. Target setting, financial power of the North, superficial ownership given to the South, ignoring local traditional realities results in antagony. Three roots of antagony have been identified: 1. therapeutic domination–medical expertise given with arrogance; 2.iatrogenic violence–good intentions that cause unintended harm; 3. the Trojan horse–Reckless acceptance of the gift as well as deceptive power positioned under the pretext of benevolence. Conclusion: The three roots of antagony; therapeutic domination, iatrogenic violence and the Trojan horse, constitute attitudes, hidden intentions and unintended consequences that influence program implementation and cause harm at different levels. Examples of therapeutic domination and the Trojan horse have highlighted the need for vigilance at the stage of establishing a partnership, to prevent more powerful partners from developing and applying hidden agendas and to strengthen accountability from the local partner. Iatrogenic violence has highlighted the need for partnership interventions to prevent good partner intentions accidentally producing bad outcomes. [ABSTRACT FROM AUTHOR]

Background: Complementary and alternative medicine (CAM) is very popular with patients frequently combining it with orthodox health care. The high prevalence of CAM use and satisfaction with CAM reported by patients directly challenges an orthodox system that can only approve such use if it results from the application of biomedical concepts and science. Studies highlighting this as a cultural, sociological and historical phenomenon emphasise the value of choice for consumers of health care. Musculoskeletal conditions typify common problems for which the effectiveness of orthodox care is often unclear. We postulated that the reasons people give for using or not using CAM for musculoskeletal conditions, would therefore indicate the full range of expectations that people have of health care. Furthermore, these reasons would indicate how much people feel orthodox health care is or is not meeting their expectations. Therefore, this study aims to investigate people’s reasons for choosing or avoiding CAM for non-traumatic musculoskeletal conditions. Methods: A systematic search and narrative synthesis was conducted of published qualitative and quantitative studies related to CAM and non-traumatic musculoskeletal conditions. Results: We identified 169 relevant papers detailing 152 separate studies, from which 1486 justifications were extracted concerning CAM use. Content analysis resulted in 11 distinct categories across four themes: practical aspects of care, clinical effectiveness, non-clinical outcomes of care, and a person’s philosophy of illness and care. People provided similar rationales for both using and avoiding CAM, emphasising that, whilst CAM is perceived by many patients with musculoskeletal conditions to fill gaps in care (such as practitioner time or quality of the therapeutic relationship), orthodox care also seeks to deliver these aspects of care. However, people who used CAM also highlighted its alignment with their general philosophy and ideas about illness and health care, and often emphasised CAM’s capacity to give them control over their condition and its treatment. Conclusion: Currently, CAM appears to have a significant role for patients with common painful long-term conditions in providing choices to enable individual needs to be met. [ABSTRACT FROM AUTHOR]

Objective: Gestural interfaces allow accessing and manipulating Electronic Medical Records (EMR) in hospitals while keeping a complete sterile environment. Particularly, in the Operating Room (OR), these interfaces enable surgeons to browse Picture Archiving and Communication System (PACS) without the need of delegating functions to the surgical staff. Existing gesture based medical interfaces rely on a suboptimal and an arbitrary small set of gestures that are mapped to a few commands available in PACS software. The objective of this work is to discuss a method to determine the most suitable set of gestures based on surgeon’s acceptability. To achieve this goal, the paper introduces two key innovations: (a) a novel methodology to incorporate gestures’ semantic properties into the agreement analysis, and (b) a new agreement metric to determine the most suitable gesture set for a PACS. Materials and methods: Three neurosurgical diagnostic tasks were conducted by nine neurosurgeons. The set of commands and gesture lexicons were determined using a Wizard of Oz paradigm. The gestures were decomposed into a set of 55 semantic properties based on the motion trajectory, orientation and pose of the surgeons’ hands and their ground truth values were manually annotated. Finally, a new agreement metric was developed, using the known Jaccard similarity to measure consensus between users over a gesture set. Results: A set of 34 PACS commands were found to be a sufficient number of actions for PACS manipulation. In addition, it was found that there is a level of agreement of 0.29 among the surgeons over the gestures found. Two statistical tests including paired t-test and Mann Whitney Wilcoxon test were conducted between the proposed metric and the traditional agreement metric. It was found that the agreement values computed using the former metric are significantly higher (p < 0.001) for both tests. Conclusions: This study reveals that the level of agreement among surgeons over the best gestures for PACS operation is higher than the previously reported metric (0.29 vs 0.13). This observation is based on the fact that the agreement focuses on main features of the gestures rather than the gestures themselves. The level of agreement is not very high, yet indicates a majority preference, and is better than using gestures based on authoritarian or arbitrary approaches. The methods described in this paper provide a guiding framework for the design of future gesture based PACS systems for the OR. [ABSTRACT FROM AUTHOR]

With recent aging demographic trends, the needs for enhancing geo-spatial analysis capabilities and monitoring the status of accessibilities of its citizens with healthcare services have increased. The accessibility to healthcare is determined not only by geographic distances to service locations, but also includes travel time, available modes of transportation, and departure time. Having access to the latest and accurate information regarding the healthcare accessibility allows the municipal government to plan for improvements, including expansion of healthcare infrastructure, effective labor distribution, alternative healthcare options for the regions with low accessibilities, and redesigning the public transportation routes and schedules. This paper proposes a new method named, Seoul Enhanced 2-Step Floating Catchment Area (SE2SFCA), which is customized for the city of Seoul, where population density is higher and the average distance between healthcare-service locations tends to be shorter than the typical North American or European cities. The proposed method of SE2SFCA is found to be realistic and effective in determining the weak accessibility regions. It resolves the over-estimation issues of the past, arising from the assignment of high healthcare accessibility for the regions with large hospitals and high density of population and hospitals. [ABSTRACT FROM AUTHOR]

Background: The availability of a skilled health professional (nurse, midwife or doctor) who has been trained and is fit for practice to provide maternity care is fundamental in scaling down and ending preventable maternal and child deaths. Knowing the determinants of the development of ideal skills for effective practice ensures that women and their babies receive quality maternity care services from skilled birth attendants who are fit for practice. This study aimed to find and build on the existing evidence addressing aspects linked to competence and confidence development during training among students, newly qualified nurses, doctors and midwives from a global perspective. Methods: A literature review was undertaken, using the 'SPIDER' search strategy to identify relevant papers from multiple databases. Studies were included if they were written in English and related to midwives, nurses and medical doctors when they were students, newly qualified professionals or after they had been working for 3-4 months. Opinion or non-empirical papers, editorials, conference papers and empirical articles with abstracts were excluded. Search words were used to identify papers that examined competence and confidence development while training these health professionals. A total of 2281 papers were identified, from countries in Europe, Australia, Asia, America and Africa. Overall, 62 papers were analysed. Results: One core category, 'learning environment', emerged, with two overarching subcategories, 'internal environment' and 'external environment' when examining facilitators and barriers to competence and confidence development. Conclusions: Facilitators and barriers to competence and confidence development are centred on the learning and practice environment. These are difficult to separate, as they are driven by either the student's or the newly qualified professional's experience with the learning and practice environment. This highlights the need for diversity and open mindedness among mentors and administrators in manipulating the environment to the benefit of either the student or the newly qualified professional so that mothers and their babies receive quality care. [ABSTRACT FROM AUTHOR]

Background: Increasing feminization of medical professions is well-acknowledged. However, this does not always equate to equitable representation of women within medicine, regarding their socio-demographic indicators, regions, sectors and fields of practice. Thus, this paper quantifies the gap in supply of female medical doctors in relation to demand, towards reaching different gender equity scenarios.Methods: A retrospective review of the Health Professions Council of South Africa's (HPCSA) database on registered medical doctors (medical practitioners and medical specialists) from 2002 until 2019 was utilized as an indicator of supply. Descriptive statistics were used to summarize data, and inferential statistics (considering a significance level of 0.05) were utilized to determine the association between the number of male and female doctors, disaggregated by demographic variables. We forecasted future gaps of South African male and female doctors up to 2030, based on maintaining the current male-to-female ratio and attaining an equitable ratio of 1:1.Results: While the ratio of female doctors per 10 000 population has increased between 2000 and 2019, from 1.2 to 3.2, it remains substantially lower than the comparative rate for male doctors per 10 000 population which increased from 3.5 in 2000 to 4.7 in 2019. Men continue to dominate the medical profession in 2019, representing 59.4% (27,579) of medical doctors registered with the HPCSA with females representing 40.6% (18,841), resulting in a male-to-female ratio of 1:0.7. Female doctors from the Black population group have constantly grown in the medical workforce from 4.4% (2000), to 12.5% (2019). There would be a deficit of 2242 female doctors by 2030 to achieve a 1:1 ratio between male and female medical doctors. An independent-samples t-test revealed that there was a significant difference in the number of male and female doctors. The Kruskal-Wallis test indicated that there was a sustained significant difference in terms of the number of male and female doctors by population groups and geographical distribution.Conclusions: Based on the investigation, we propose that HRH planning incorporate forecasting methodologies towards reaching gender equity targets to inform planning for production of healthcare workers. [ABSTRACT FROM AUTHOR]

Background: Diabetes is a chronic disease commonly managed by family physicians, with the most prevalent complication being cardiovascular disease (CVD). Clinical practice guidelines have been developed to support clinicians in the care of diabetic patients. We conducted a pragmatic cluster randomized controlled trial (RCT) of a printed educational toolkit aimed at improving CVD management in diabetes in primary care, and found no effect, and indeed, the possibility of some harm. We conducted a qualitative evaluation to study the strategy for guideline implementation employed in this trial, and to understand its effects. This paper focuses solely on the qualitative findings, as the RCT’s quantitative results have already been reported elsewhere. Methods and Findings: All family practices in the province of Ontario had been randomized to receive the educational toolkit by mail, in either the summer of 2009 (intervention arm) or the spring of 2010 (control arm).A subset of 80 family physicians (representing approximately 10% of the practices randomized and approached, with records on 1,592 randomly selected patients with diabetes at high risk for CVD) then took part in a chart audit and reflective feedback exercise related to their own practice in comparison to the guideline recommendations. They were asked to complete two forms (one pre- and one post-audit) in order to understand their awareness of the guidelines pre-trial, their expectations regarding their individual performance pre-audit, and their reflections on their audit results. In addition, individual interviews with thirteen other family physicians were conducted. Textual data from interview transcripts and written commentary from the pre- and post-audit forms underwent qualitative descriptive analysis to identify common themes and patterns. Analysis revealed four main themes: impressions of the toolkit, awareness was not the issue, ‘it’s not me it’s my patients’, and chart audit as a more effective intervention than the toolkit. Participants saw neither the toolkit content nor its dissemination strategy to be effective, indicating they perceived themselves to be aware of the guidelines pre-trial. However, their accounts also indicated that they may be struggling to prioritize CVD management in the midst of competing demands for their attention. Upon receiving their chart audit results, many participants expressed surprise that they had not performed better. They reported that the audit results would be an important motivator for behaviour change. Conclusions: The qualitative findings outlined in this paper offer important insights into why the intervention was not effective. They also demonstrate that physicians have unperceived needs relative to CVD management and that the chart audit served to identify shortcomings in their practice of which they had been hitherto unaware. The findings also indicate that new methods of intervention development and implementation should be explored. This is important given the high prevalence of diabetes worldwide; appropriate CVD management is critical to addressing the morbidity and mortality associated with the disease. [ABSTRACT FROM AUTHOR]

Background and Aims: This study focused on the difference between perceived and desired physician empathy (pPE and dPE) in the eye of patients with inflammatory bowel disease (IBD). It was investigated if a discrepancy (ΔPE) correlates with trust and satisfaction of patients. At the same time the aim was to gain detailed information about the subjective burden of disease and the resources of IBD patients, in order to better understand them. Methods: A modified version of the German Version of the Consultation and Relational Empathy (CARE) measure was completed as a paper-and-pencil questionnaire by IBD patients attending our facility (n = 32) and as an online survey by IBD patients at other locations throughout Germany (n = 89). Patients were in average 36.3±12 years old. Results: The mean (SD) rating of pPE was 3.93 (0.96) on a scale of 1 to 5 (“poor” to “excellent”); however, the mean (SD) dPE was 4.38 (0.48) on the same scale. ΔPE correlated with perceived empathy and with patients’ satisfaction with treatment and trust in their health care providers. Patients reported quite a high subjective burden (mean [SD]: 2.93 [.63]) and named family, friends, and support groups as resources. Conclusions: Rather than assessing patient satisfaction with treatment and trust in their physician only with perceived PE, we suggest ΔPE as a useful additional parameter. [ABSTRACT FROM AUTHOR]

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Background: Tumor proliferation speed, most commonly assessed by counting of mitotic figures in histological slide preparations, is an important biomarker for breast cancer. Although mitosis counting is routinely performed by pathologists, it is a tedious and subjective task with poor reproducibility, particularly among non-experts. Inter- and intraobserver reproducibility of mitosis counting can be improved when a strict protocol is defined and followed. Previous studies have examined only the agreement in terms of the mitotic count or the mitotic activity score. Studies of the observer agreement at the level of individual objects, which can provide more insight into the procedure, have not been performed thus far. Methods: The development of automatic mitosis detection methods has received large interest in recent years. Automatic image analysis is viewed as a solution for the problem of subjectivity of mitosis counting by pathologists. In this paper we describe the results from an interobserver agreement study between three human observers and an automatic method, and make two unique contributions. For the first time, we present an analysis of the object-level interobserver agreement on mitosis counting. Furthermore, we train an automatic mitosis detection method that is robust with respect to staining appearance variability and compare it with the performance of expert observers on an “external” dataset, i.e. on histopathology images that originate from pathology labs other than the pathology lab that provided the training data for the automatic method. Results: The object-level interobserver study revealed that pathologists often do not agree on individual objects, even if this is not reflected in the mitotic count. The disagreement is larger for objects from smaller size, which suggests that adding a size constraint in the mitosis counting protocol can improve reproducibility. The automatic mitosis detection method can perform mitosis counting in an unbiased way, with substantial agreement with human experts. [ABSTRACT FROM AUTHOR]

Despite the significant responsibility that physicians have in healthcare delivery, we know surprisingly little about why physician practice styles vary within or across institutions. Estimating variation in physician practice styles is complicated by the fact that patients are rarely randomly assigned to physicians. This paper uses the quasi-random assignment of patients to physicians in emergency departments (EDs) to show how physicians vary in their treatment of patients with minor injuries. The results reveal a considerable degree of variation in practice styles within EDs; physicians at the 75th percentile of the spending distribution spend 20% more than physicians at the 25th percentile. Observable physician characteristics do not explain much of the variation across physicians, but there is a significant degree of sorting between physicians and EDs over time, with high-cost physicians sorting into high-cost EDs as they gain experience. The results may shed light on why some EDs remain persistently higher-cost than others. [ABSTRACT FROM AUTHOR]

Telemedicine has become an increasingly popular option for long-distance health care and continuing education. As information and communication technology is underdeveloped in China, telemedicine develops slowly. At present, telemedicine consultation centers are situated mainly in developed cities, such as Beijing, Shanghai, and Guangzhou. In many less developed regions, such as northwest China, the conditions or related facilities are not available for the application of a better medical service. Accordingly, the aim of this paper was to introduce the construction and application of a telemedicine consultation center in Gansu Province in the northwest of China. In addition, the function of Gansu Provincial Telemedicine Consultation Center on emergency public events was introduced. As a whole, there was a great demand for telemedicine service in the local medical institutions. In the telemedicine consultation center, the telemedicine equipments and regulations were needed to be improved. The function of telemedicine service was not fully used, there was a large space to be applied and the publicity of telemedicine service was important. What is important was that telemedicine played a significance role in promoting the medical policy reform, improving the medical environment and launching the remote rescue in the emergency public events. This paper emphasizes the health care challenges of poor regions, and indicates how to share the high-quality medical service of provincial hospitals effectively and how to help residents in resource-poor environments. [ABSTRACT FROM AUTHOR]

Objectives: Our hospital replaced the format for delivering portable antimicrobial prescribing guidance from a paper-based pocket guide to a smartphone application (app). We used this opportunity to assess the relationship between its use and the attitudes and behaviours of antimicrobial prescribers. Methods: We used 2 structured cross-sectional questionnaires issued just prior to and 3 months following the launch of the smartphone app. Ordinal Likert scale responses to both frequencies of use and agreement statements permitted quantitative assessment of the relationship between variables. Results: The smartphone app was used more frequently than the pocket guide it replaced (p < 0.01), and its increased use was associated with sentiments that the app was useful, easy to navigate and its content relevant. Users who used the app more frequently were more likely to agree that the app encouraged them to challenge inappropriate prescribing by their colleagues (p = 0.001) and were more aware of the importance of antimicrobial stewardship (p = 0.005). Reduced use of the app was associated with agreement that senior physicians’ preferences for antimicrobial prescribing would irrespectively overrule guideline recommendations (p = 0.0002). Conclusions: Smartphone apps are an effective and acceptable format to deliver guidance on antimicrobial prescribing. Our findings suggest that they may empower users to challenge incorrect prescribing, breaking well-established behaviours, and thus supporting vital stewardship efforts in an era of increased antimicrobial resistance. Future work will need to focus on the direct impact on drug prescriptions as well as identifying barriers to implementing smartphone apps in other clinical settings. [ABSTRACT FROM AUTHOR]

Floating Catchment Area (FCA) methods are a popular tool to investigate accessibility to public facilities, in particular health care services. FCA approaches are attractive because, unlike other accessibility measures, they take into account the potential for congestion of facilities. This is done by 1) considering the population within the catchment area of a facility to calculate a variable that measures level of service, and then 2) aggregating the level of service by population centers subject to catchment area constraints. In this paper we discuss an effect of FCA approaches, an artifact that we term demand and level of service inflation. These artifacts are present in previous implementations of FCA methods. We argue that inflation makes interpretation of estimates of accessibility difficult, which has possible deleterious consequences for decision making. Next, we propose a simple and intuitive approach to proportionally allocate demandand and level of service in FCA calculations. The approach is based on a standardization of the impedance matrix, similar to approaches popular in the spatial statistics and econometrics literature. The result is a more intiuitive measure of accessibility that 1) provides a local version of the provider-to-population ratio; and 2) preserves the level of demand and the level of supply in a system. We illustrate the relevant issues with some examples, and then empirically by means of a case study of accessibility to family physicians in the Hamilton Census Metropolitan Area (CMA), in Ontario, Canada. Results indicate that demand and supply inflation/deflation affect the interpretation of accessibility analysis using existing FCA methods, and that the proposed adjustment can lead to more intuitive results. [ABSTRACT FROM AUTHOR]

Introduction: If interprofessional collaborative practice is to be an important component of healthcare reform, then an evidentiary base connecting interprofessional education to interprofessional practice with significantly improved health and healthcare outcomes is an unconditional necessity. This study is a scoping review of the current peer reviewed literature linking interprofessional collaborative care and interprofessional collaborative practice to clearly identified healthcare and/or patient health-related outcomes. The research question for this review was: What does the evidence from the past decade reveal about the impact of Interprofessional collaborative practice on patient-related outcomes in the US healthcare system? Materials and methods: A modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was followed. Results: Of an initial 375 articles retrieved 20 met review criteria. The most common professions represented in the studies reviewed were physicians, pharmacists and nurses. Primary care was the most common care delivery setting and measures related to chronic disease the most commonly measured outcomes. No study identified negative impacts of interprofessional collaborative practice. Eight outcome categories emerged from a content analysis of the findings of the reviewed studies. Conclusions: The results suggest a need for more research on the measurable impact of interprofessional collaborative practice and/or care on patient health-related outcomes to further document its benefits and to explore the models, systems and nature of collaborations that best improve population health, increase patient satisfaction, and reduce cost of care. [ABSTRACT FROM AUTHOR]

Objective: Critical illness affects health systems globally, but low- and middle-income countries (LMICs) bear a disproportionate burden. Due to a paucity of data, the capacity to care for critically ill patients in LMICs is largely unknown. Haiti has the lowest health indices in the Western Hemisphere. In this study, we report results of the first known nationwide survey of critical care capacity in Haiti. Design: Nationwide, cross-sectional survey of Haitian hospitals in 2017–2018. Setting: Haiti. Subjects: All Haitian health facilities with at least six hospital beds. Interventions: Electronic- and paper-based survey. Results: Of 51 health facilities identified, 39 (76.5%) from all ten Haitian administrative departments completed the survey, reporting 124 reported ICU beds nationally. Of facilities without an ICU, 20 (83.3%) care for critically ill patients in the emergency department. There is capacity to ventilate 62 patients nationally within ICUs and six patients outside of the ICU. One-third of facilities with ICUs report formal critical care training for their physicians. Only five facilities met criteria for a Level 1 ICU as defined by the World Federation of Societies of Intensive and Critical Care Medicine. Self-identified barriers to providing more effective critical care services include lack of physical space for critically ill patients, lack of equipment, and few formally trained physicians and nurses. Conclusions: Despite a high demand for critical care services in Haiti, current capacity remains insufficient to meet need. A significant amount of critical care in Haiti is provided outside of the ICU, highlighting the important overlap between emergency and critical care medicine in LMICs. Many ICUs in Haiti lack basic components for critical care delivery. Streamlining critical care services through protocol development, education, and training may improve important clinical outcomes. [ABSTRACT FROM AUTHOR]

Primary health care has been recognized as a critical strategy for improving population health in developing countries. This paper investigates the effect of primary care physicians on the infant mortality rate in Brazil using a dynamic panel data approach. This method accounts for the endogeneity problem and the persistence of infant mortality over time. The empirical analysis uses an eight-year panel of municipalities between 2005 and 2012. The results indicate that primary care physician supply contributed to the decline of infant mortality in Brazil. An increase of one primary care physician per 10,000 population was associated with 7.08 fewer infant deaths per 10,000 live births. This suggests that, in addition to other determinants, primary care physicians can play an important role in accounting for the reduction of infant mortality rates. [ABSTRACT FROM AUTHOR]

Background: This study reports on physicians’ experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities. Methods: Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings. Findings: In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse. Interpretation: Our findings show that care providers find the treatment of patients with chronic pain–especially those patients also experiencing poverty–to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients’ social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision. [ABSTRACT FROM AUTHOR]

Background: BMI is a feasible and recommended measure for overweight and obesity screening in children and adolescents. The study aimed to determine how often physicians correctly identified obesity/ overweight status in children and adolescents by using BMI percentile charts. Methods: This retrospective cross-sectional study reviewed the paper medical records of children and adolescents (6–14 years) who visited family medicine and pediatric outpatient clinics (Jan-June 2012) in a medical city in Riyadh. Investigators calculated BMI percentiles (using height, weight, age and gender data retrieved from the records) in order to identify patient weight status. Physician documentation of obesity/overweight diagnoses in patient problem lists were cross checked against their BMI percentile to assess the accuracy of physicians’ identification of weight status. The recommended management plan for identified patients was also recorded. Results: A total of 481 charts were reviewed, 213 (44%) children were seen by family medicine physicians and 268 (56%) by pediatricians. The sample was equally distributed by gender. Height was undocumented for 13% (71) of visiting patients. Eighteen percent of patients (86) were classified as overweight (35)/obese (51) according to age and sex adjusted BMI percentile. Physicians’ correctly identified and documented weight status in 20% of overweight/obese patients: 17 out of 86 subjects. Weight status identification was higher among pediatricians—25% as compared to family medicine physicians—10% [p = 0.08]. Dietary referral was the most common management plan for the identified children. Physicians were more likely to identify obese children {≥95th} compared to overweight {≥85th - 95th} children. Subjects whose BMI for age classified them into the highest BMI percentile category {≥95th} were more likely to be correctly identified (29%) compared to those classified within {≥85th - 95th} category—6% [p = 0.007]. Conclusion: Physician identification of obesity/ overweight status for children and adolescents was low, irrespective of their specialty, and despite the condition being prevalent in the sample. Future research that concentrates on interventions that may improve documentation of obesity/overweight diagnoses and parameters needed for BMI indices would be beneficial. [ABSTRACT FROM AUTHOR]

Computer-aided polyp detection in gastric gastroscopy has been the subject of research over the past few decades. However, despite significant advances, automatic polyp detection in real time is still an unsolved problem. In this paper, we report on a convolutional neural network (CNN) for polyp detection that is constructed based on Single Shot MultiBox Detector (SSD) architecture and which we call SSD for Gastric Polyps (SSD-GPNet). To take full advantages of feature maps’ information from the feature pyramid and to acquire higher accuracy, we re-use information that is abandoned by Max-Pooling layers. In other words, we reuse the lost data from the pooling layers and concatenate that data as extra feature maps to contribute to classification and detection. Meanwhile, in the feature pyramid, we concatenate feature maps of the lower layers and feature maps that are deconvolved from upper layers to make explicit relationships between layers and to effectively increase the number of channels. The results show that our enhanced SSD for gastric polyp detection can realize real-time polyp detection with 50 frames per second (FPS) and can improve the mean average precision (mAP) from 88.5% to 90.4%, with only a little loss in time-performance. And the further experiment shows that SSD-GPNet has excellent performance in improving polyp detection recalls over 10% (p = 0.00053), especially in small polyp detection. This can help endoscopic physicians more easily find missed polyps and decrease the gastric polyp miss rate. It may be applicable in daily clinical practice to reduce the burden on physicians. [ABSTRACT FROM AUTHOR]

Poor intra-facility maternity care is a major contributor to maternal mortality in low- and middle-income countries. Close to 830 women die each day due to preventable maternal complications, partly due to the increasing number of women giving birth in health facilities that are not adequately resourced to manage growing patient populations. Barriers to adequate care during the ‘last mile’ of healthcare delivery are attributable to deficiencies at multiple levels: education, staff, medication, facilities, and delays in receiving care. Moreover, the scope and multi-scale interdependence of these factors make individual contributions of each challenging to analyze, particularly in settings where basic data registration is often lacking. To address this need, we have designed and implemented a novel systems-level and dynamic mathematical model that simulates the impact of hospital resource allocations on maternal mortality rates at Mnazi Mmoja Hospital (MMH), a referral hospital in Zanzibar, Tanzania. The purpose of this model is to provide a rigorous and flexible tool that enables hospital administrators and public health officials to quantitatively analyze the impact of resource constraints on patient outcomes within the maternity ward, and prioritize key areas for further human or capital investment. Currently, no such tool exists to assist administrators and policy makers with effective resource allocation and planning. This paper describes the structure and construct of the model, provides validation of the assumptions made with anonymized patient data and discusses the predictive capacity of our model. Application of the model to specific resource allocations, maternal treatment plans, and hospital loads at MMH indicates through quantitative results that medicine stocking schedules and staff allocations are key areas that can be addressed to reduce mortality by up to 5-fold. With data-driven evidence provided by the model, hospital staff, administration, and the local ministries of health can enact policy changes and implement targeted interventions to improve maternal health outcomes at MMH. While our model is able to determine specific gaps in resources and health care delivery specifically at MMH, the model should be viewed as an additional tool that may be used by other facilities seeking to analyze and improve maternal health outcomes in resource constrained environments. [ABSTRACT FROM AUTHOR]

In 2010, the UK embarked on a self-imposed programme of contractionary measures signalling the beginning of a so-called “age of austerity” for the country. It was argued that budgetary cuts were the most appropriate means of eliminating deficits and decreasing national debt as percentage of General Domestic Product (GDP). Although the budget for the National Health Service (NHS) was not reduced, a below-the-average increase in funding, and cuts in other areas of public spending, particularly in social care and welfare spending, impacted significantly on the NHS. One of the areas where the impact of austerity was most dramatically felt was in Accidents and Emergency Departments (A&E). A number of economic and statistical reports and quantitative studies have explored and documented the effects of austerity in healthcare in the UK, but there is a paucity of research looking at the effects of austerity from the standpoint of the healthcare professionals. In this paper, we report findings from a qualitative study with healthcare professionals working in A&E departments in England. The study findings are presented thematically in three sections. The main theme that runs through all three sections is the perceptions of austerity as shaping the functioning of A&E departments, of healthcare professions and of professionals themselves. The first section discusses the rising demand for services and resources, and the changed demographic of A&E patients—altering the meaning of A&E from ‘Accidents and Emergencies’ to the Department for ‘Anything and Everything’. The second section in this study’s findings, explores how austerity policies are perceived to affect the character of healthcare in A&E. It discusses how an increased focus on the procedures, time-keeping and the operationalisation of healthcare is considered to detract from values such as empathy in interactions with patients. In the third section, the effects of austerity on the morale and motivations of healthcare professionals themselves are presented. Here, the concepts of moral distress and burnout are used in the analysis of the experiences and feelings of being devalued. From these accounts and insights, we analyse austerity as a catalyst or mechanism for a significant shift in the practice and function of the NHS–in particular, a shift in what is counted, measured and valued at departmental, professional and personal levels in A&E. [ABSTRACT FROM AUTHOR]

Background: Leprosy remains a disease of concern in many countries including Nepal. To achieve the target of elimination, the WHO strategy promotes comprehensive education of patients, healthcare workers (HCWs), and the public on leprosy-related issues. However most educational programs are based on the concerns of HCWs and not on patients’ needs. The objective of this paper is to explore the educational needs of leprosy affected patients in Nepal and compare them to the needs perceived by HCWs. Methodology/principal findings: Semi directive interviews were conducted with patients and HCWs. The data was analyzed using the basic interpretative qualitative framework. The study was conducted in two leprosy referral centers, one university hospital and one primary health care center: Lalgadh Leprosy Hospital and Services Centre, Anandaban Hospital and its satellite clinic in Patan, B. P. Koirala Institute of Health Sciences in Dharan, and the Itahari primary health care centre. The results show that there remains a lack of knowledge regarding the disease (origins, manifestations, prevention and treatment) contributing to late care seeking behavior and high levels of stigma, with an important psychological and financial stress for patients. All of the HCWs displayed a good understanding of patients’ difficulties and needs and acknowledged the key role of patient education. However, they expressed several challenges in managing patients due to lack of time, human resources and training in patient education. Conclusions/significance: Further efforts need to be made to increase patients’ general knowledge of the disease in order to motivate them to seek healthcare earlier and change their perception of the disease to reduce stigma. HCWs need proper training in patient education and counseling for them to acquire the necessary skills required to address the different educational needs of their patients. The use of lay and peer counselors would be an option to address the workload and lack of time expressed by HCWs. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about the physician characteristics associated with appraisal skills of research evidence, especially the assessment of the validity of study methodology. This study aims to explore physician characteristics associated with proper assessment of overstated conclusions in research abstracts. Design: A secondary analysis of a randomized controlled trial. Setting and participants: We recruited 567 volunteers from the Japan Primary Care Association. Methods: Participants were randomly assigned to read the abstract of a research paper, with or without an overstatement, and to rate its validity. Our primary outcome was proper assessment of the validity of its conclusions. We investigated the association of physician characteristics and proper assessment using logistic regression models and evaluated the interaction between the associated characteristics and overstatement. Results: We found significant associations between proper assessment and post-graduate year (odds ratio [OR] = 0.67, 95% confidence interval [CI] 0.49 to 0.91, for every 10-year increase) and research experience as a primary investigator (PI; OR = 2.97, 95% CI 1.65 to 5.34). Post-graduate year and PI had significant interaction with overstatement (P = 0.015 and < 0.001, respectively). Among participants who read abstracts without an overstatement, post-graduate year was not associated with proper assessment (OR = 1.04, 95% CI 0.82 to 1.33), and PI experience was associated with lower scores of the validity (OR = 0.58, 95% CI 0.35 to 0.96). Conclusion: Physicians who have been in practice longer should be trained in distinguishing overstatements in abstract conclusions. Physicians with research experience might be informed that they tend to rate the validity of research lower regardless of the presence or absence of overstatements. Trial registration: . [ABSTRACT FROM AUTHOR]

Introduction: The Indian Tuberculosis (TB) Programme currently faces the dual challenges of tackling increasing numbers of drug resistant (DR) TB cases and regulating practices of a pluralistic private sector catering to TB patients. A study of health seeking behaviour of DR-TB patients in such a situation, offers an opportunity to understand the problems patients face while interacting with health systems. Methodology: Forty-six DR-TB patients drawn from 15 high TB burden wards in Mumbai were interviewed using an open ended interview tool. Interviews were audio recorded and transcribed. Pathway schematics developed from analysis of patient records, were linked to transcripts. Open coding was used to analyse these units and themes were derived after collating the codes. Results and discussion: The paper presents themes interwoven with narratives in the discussions. These include awareness-action gap among patients, role of neighbourhood providers, responsiveness of health systems, the not-such a ‘merry go round’ that patients go/are made to go on while seeking care, costs of diagnostics and treatment, and how DR-TB is viewed as the ‘big TB’. Conclusion: The recommendations are based on a preventative ethos which is sustainable, compared to interventions with top-down approaches, which get piloted, but fail to sustain impact when scaled up. [ABSTRACT FROM AUTHOR]

Background: Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa. Methods: We applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories. Results: A modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care. Conclusion: This finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts. [ABSTRACT FROM AUTHOR]

Objective: Recognizing what physicians know and do not know about a particular disease is one of the keys to designing clinical decision support systems, since these systems can fulfill complementary role by recognizing this boundary. To our knowledge, however, no study has attempted to quantify how many diseases physicians actually know and thus the boundary is unclear. This study explores a method to solve this problem by investigating whether the vocabulary assessment techniques developed in the linguistics field can be applied to assess physicians’ knowledge. Methods: The test design required us to pay special attention to disease knowledge assessment. First, to avoid imposing unnecessary burdens on the physicians, we chose a self-assessment questionnaire that was straightforward to fill out. Second, to prevent overestimation, we used a “pseudo-word” approach: fictitious diseases were included in the questionnaire, and positive responses to them were penalized. Third, we used paper-based tests, rather than computer-based ones, to further prevent participants from cheating by using a search engine. Fourth, we selectively used borderline diseases, i.e., diseases that physicians might or might not know about, rather than well-known or little-known diseases, in the questionnaire. Results: We collected 102 valid answers from 109 physicians who attended the seminars we conducted. On the basis of these answers, we estimated that the average physician knew of 2008 diseases (95% confidence interval: (1939, 2071)). This preliminary estimation agrees with the guideline for the national license examination in Japan, suggesting that this vocabulary assessment was able to evaluate physicians’ knowledge. The survey included physicians with various backgrounds, but there were no significant differences between subgroups. Other implication for researches on clinical decision support and limitation of the sampling method adopted in this study are also discussed, toward more rigorous estimation in future surveys. [ABSTRACT FROM AUTHOR]

Background: Health literacy (HL), defined as the ability to access, understand, appraise and apply health information, offers a promising approach to reduce the development of cardiovascular diseases (CVD) and to improve the management of CVD in populations. Design: We used data from nationwide cross-sectional German Health Update (GEDA2014/2015-EHIS) survey. 13,577 adults ≥ 40 years completed a comprehensive standardized paper or online questionnaire including the short form of the European Health Literacy Survey Questionnaire (HLS-EU-Q16). Methods: We compared participants with and without CVD with regard to their HL. We also analyzed the association between HL level and health care outcomes among individuals with CVD, i.e. frequency of general practitioner or specialist consultations, hospitalization and treatment delay. Results: The percentage of “problematic” or “inadequate” HL, defined as “not sufficient” HL, was significantly higher in individuals with CVD compared to without CVD (men 41.8% vs. 33.6%, women 46.7% vs. 33.4%). Having CVD was independently associated with “not sufficient” HL after adjusting for age, education, income, health consciousness and social support (adjusted OR: men 1.36, women 1.64). Among participants with CVD, individuals with “inadequate” HL were more likely to have more than 6 general practitioner consultations (49.3% vs. 28.7%), hospitalization (46.6% vs. 36.0%) in the last 12 months and to experience delay in getting health care because of long waiting lists for an appointment (30.7% vs. 18.5%) compared to participants with “sufficient” HL. Conclusion: “Problematic” or “inadequate” HL is independently associated with CVD and health care use. This is a challenge and an opportunity for both CVD prevention and treatment. [ABSTRACT FROM AUTHOR]

Objectives: Research concentrating on continuity of care for chronic, non-communicable disease (NCD) patients in resource-constrained settings is currently limited and focusses on inpatients. Outpatient care requires attention as this is where NCD patients often seek treatment and optimal handover of information is essential. We investigated handover, healthcare communication and barriers to continuity of care for chronic NCD outpatients in India. We also explored potential interventions for improving storage and exchange of healthcare information. Methods: A mixed-methods design was used across five healthcare facilities in Kerala and Himachal Pradesh states. Questionnaires from 513 outpatients with cardiovascular disease, chronic respiratory disease, or diabetes covered the form and comprehensiveness of information exchange between healthcare professionals (HCPs) and between HCPs and patients. Semi-structured interviews with outpatients and HCPs explored handover, healthcare communication and intervention ideas. Barriers to continuity of care were identified through triangulation of all data sources. Results: Almost half (46%) of patients self-referred to hospital outpatient clinics (OPCs). Patient-held healthcare information was often poorly recorded on unstructured sheets of paper; 24% of OPC documents contained the following: diagnosis, medication, long-term care and follow-up information. Just 55% of patients recalled receiving verbal follow-up and medication instructions during OPC appointments. Qualitative themes included patient preference for hospital visits, system factors, inconsistent doctor-patient communication and attitudes towards medical documents. Barriers were hospital time constraints, inconsistent referral practices and absences of OPC medical record-keeping, structured patient-held medical documents and clinical handover training. Patients and HCPs were in favour of the introduction of patient-held booklets for storing and transporting medical documents. Conclusions: Deficiencies in communicative practices are compromising the continuity of chronic NCD outpatient care. Targeted systems-based interventions are urgently required to improve information provision and exchange. Our findings indicate that well-designed patient-held booklets are likely to be an acceptable, affordable and effective part of the solution. [ABSTRACT FROM AUTHOR]

Background: This paper describes the association between workplace violence and job satisfaction among physicians and nurses in Macau. Convenience sampling was sourced from six health centers under the Macau Health Bureau. Methods: This study uses a cross-sectional self-administrative survey. The study used case studies research instruments for workplace violence in the health sector by country (from the ILO, ICN, WHO, PSI), the Minnesota Satisfaction Questionnaire and Perceived Stress Scale. The data collection period spanned from August to December, 2014. Data analysis: Multiple logistic regression examines levels of intrinsic and extrinsic satisfaction in physicians and nurses and significant correlates affecting their job satisfaction. Results: A total of 720 (14.9% physicians) participants were recruited. 57.2% of participants reported physical and psychological workplace violence in the preceding year. The most common forms of workplace violence were verbal abuse (53.4%), physical assault (16.1%), bullying / harassment (14.2%), sexual harassment (4.6%) and racial harassment (2.6%). Nurses were at a significantly higher risk of physical assault and verbal abuse compared to physicians. Patients, patients’ relatives, and colleagues were the main perpetrators. Worry about WPV, on-call duty and shift work, experience of bullying and verbal abuse and employment sector emerged as significant correlates affecting the intrinsic and extrinsic job satisfaction of physicians and nurses. Frontline staff, aged 30 and 39, coming from an ethnic minority, and perceived stress were significant correlates affecting nurses’ job satisfaction. Conclusions: WPV remains a significant concern in healthcare settings in Macau. Stakeholders should legally enforce a zero-tolerance policy towards WPV within healthcare workplaces. WPV is detrimental to healthcare professionals’ mental wellbeing, risking irreversible physical and psychological harm for its victims. [ABSTRACT FROM AUTHOR]

Objective: The aim of this paper is to investigate how doctors working in primary health care in Latin American address patients with common mental disorders and to investigate how stigma can affect their clinical decisions. Methods: Using a cross-sectional design, we applied an online self-administered questionnaire to a sample of 550 Primary Care Physicians (PCPs) from Bolivia, Brazil, Cuba and Chile. The questionnaire collected information about sociodemographic variables, training and experience with mental health care. Clinicians’ stigmatizing attitudes towards mental health were measured using the Mental Illness Clinicians' Attitudes Scale (MICA v4). The clinical decisions of PCPs were assessed through three clinical vignettes representing typical cases of depression, anxiety and somatization. Results: A total of 387 professionals completed the questionnaires (70.3% response rate). The 63.7% of the PCPs felt qualified to diagnose and treat people with common mental disorders. More than 90% of the PCPs from Bolivia, Cuba and Chile agreed to treat the patients presented in the three vignettes. We did not find significant differences between the four countries in the scores of the MICA v4 stigma levels, with a mean = 36.3 and SD = 8.3 for all four countries. Gender (p = .672), age (p = .171), training (p = .673) and years of experience (p = .28) were unrelated to stigma. In the two multivariate regression models, PCPs with high levels of stigma were more likely to refer them to a psychiatrist the patients with depression (OR = 1.03, 95% CI, 0.99 to 1.07 p<0.05) and somatoform symptoms somatoform (OR = 1.03, 95% CI, 1.00 to 1.07, p<0.05) to a psychiatrist. Discussion: The majority of PCPs in the four countries were inclined to treat patients with depression, anxiety and somatoform symptoms. PCPs with more levels of stigma were more likely to refer the patients with depression and somatoform symptoms to a psychiatrist. Stigmatizing attitudes towards mental disorders by PCPs might be important barriers for people with mental health problems to receive the treatment they need in primary care. [ABSTRACT FROM AUTHOR]