Understanding the Implementation of Hierarchical Medical System Policy: An Interrupted Time Series Analysis of a Pilot Scheme in China

Background The Chinese healthcare system faces a dilemma between its hospital-centric approach to healthcare delivery and a rapidly aging population that requires strong primary care. To improve system efficiency and continuity of care, the Hierarchical Medical System (HMS) policy package was implemented in 2015 in Zhejiang province, China. This paper investigated the impact of HMS on the local healthcare system.MethodsWe conducted a repeated cross-sectional study with quarterly data collected between 2010 and 2018 from Yinzhou district, Ningbo. The data was analyzed with an interrupted time series (ITS) design to assess the impact of HMS on the changes of three outcome variables: primary care physicians (PCPs) patient encounter ratio (i.e., the mean quarterly number of patient encounters of PCPs divided by that of all other physicians), PCP degree ratio (i.e., the mean degree of PCPs divided by that of all other physicians), PCP betweenness centrality ratio (i.e., the mean betweenness centrality of PCPs divided by that of all other physicians). Results272,267 patients visited doctors for hypertension between 2010 and 2018. Compared to the counterfactual in the fourth quarter of 2018, the PCP patient encounter ratio rose by 42.7% (95%CI: 27.1—58.2, p<0.001), the PCP degree ratio increased by 23.6% (95%CI: 8.6—38.5, p<0.01), and the PCP betweenness centrality ratio grew by 129.4% (95%CI: 87.1—171.7, p<0.001).ConclusionsThe HMS policy can incentivize patients to visit primary care facilities and enhance the centrality of PCPs within their professional network. Local policymakers should sustain HMS policy efforts to obtain long-term and large-scale benefits.

Slow motion ethics: Narrative responsibility in clinical care

Narrative theory is a dynamic and evolving field of inquiry that has made tremendous inroads in the medical humanities over the past 40 years. Numerous authors have popularized the idea that “thinking narratively” can produce important insights about the illness experience for physician and patient alike. This paper draws on aspects of narrative theory to emphasize the moral responsibilities that arise when we step into another person's life narrative, becoming a character in her or his story. This has especially significant ethical implications for the physician–patient encounter in that each character in this shared story experiences time somewhat differently. This gives rise to the notion of “slow motion ethics” and a somewhat unique perspective on the moral responsibilities clinicians bear toward their patients.

Designing a Predictive Model for Antiretroviral Regimen at the Antiretroviral Therapy Center in Chiro Hospital, Ethiopia

Nowadays, the huge amount of patient’s data significantly increases with respect to the time in repositories and data mining is increasingly used as an emerging research area in medical fields for extracting useful and previously unknown insights/patterns from the repository data. These unknown patterns/hidden insights can help in discovering new knowledge hidden in these data repositories. From the observation, different ARV regimens were ordered for different patients. However, combination of these drugs causes different side effects on the patients. It has been observed that there was a lack of predictive studies and designed models available in hospitals specifically ART Centers that accurately determine or classify the patient’s ARV regimen to TDF + 3TC + EFV, TDF + 3TC + NVP, AZT + 3TC + ATV/R, AZT + 3TC + LPV/R, TDF + 3TC + LVP/R, TDF + 3TC + ATV/R, 8888, and ABC + 3TC + LPV/R. In order to solve these kinds of problems, we built an accurate classifier system or model using parameters like Patient Age, Patient Encounter Day, Patient Encounter Month, Patient Encounter Year, Patient Weight, Patient CD4 Count Adult, Patient TB Screen, Patient Following WHO Stage, Patient CD4 Percent Child, Patient Regimen Specify, Patient Regimen, and so on. The general objective of this research was predictive modeling for the patient’s ARV regimen class through data mining techniques so as to improve them. The study used the CRIPS-DM methodology to find and interpret patterns in repositories. A decision tree (J48 and Random Forest) algorithm was used for classification. Using all tested classifiers, the investigation of the study shows that the total accuracy was more than 60%. On the other hand, among different classifications, class H (ABC + 3TC + LPV/R) has shown the worst prediction. But it was revealed that the J48 classifier relatively produces higher classification accuracy for the D (AZT-3TC-NVP) regimen. Here, classification depended on the selected parameters, which revealed that prediction accuracy value differed among all classifiers and the selected attributes. Finally, the study concluded that data mining can be used as a significant technique to discover patient regimen based on salient affecting factors with 96.1% precision achieved. Ensemble learning resolves the categorizing models of greater anticipating performance with different learning algorithms. This model aligned with sentimental investigation to magnify the appearances of the dataset either from the social media or from primary data collection. The empirical investigation with different parameters shows the detailed improvement of their learning methods.

Evaluating the reference range of a new high-sensitivity troponin assay using retrospective review of laboratory data

Rapid diagnosis of myocardial infarction (MI) in the emergency department (ED) is critical for proper patient management and optimal patient outcomes. High-sensitivity plasma troponin assays may help identify cardiac injury sooner by having better analytical sensitivity. When our institution first adopted the Beckman-Coulter high-sensitivity troponin I assay (hsTnI), cardiologists were hesitant to use the upper reference limit (URL) provided by the manufacturer (&lt; 0.0136 ng/mL for female patients, &lt; 0.0198 ng/mL for male patients), due to concerns regarding assay specificity at the URL. To help transition to the new high-sensitivity assay and its potential benefits, we began using the new hsTnI assay, but maintained the URL of the previous automated immunoassay, which was based on the 99th percentile of a healthy population (&lt; 0.04 ng/mL = negative; 0.04 - 0.4 ng/mL = suspected MI, above the 99th percentile; &gt; 0.4 ng/mL = likely MI). The purpose of the current study was to assess the suitability of the manufacturer’s URL for the new hsTnI assay for our health system’s patient population. To do this, we extracted patient encounter ICD-10 diagnosis codes, diagnosis-related groups (DRGs), and hsTnI results from our institution’s enterprise data warehouse and the laboratory information system for patients seen between Jan 2, 2020 and Aug 31, 2020. We included all patients who presented to the ED and received hsTnI testing. Each patient encounter was subsequently categorized as having MI or no-MI, based on diagnosis codes and DRGs. The first troponin test for each encounter was selected for analysis. The URL recommended by the manufacturer identified 92% and 100% of female and male patients with MI, respectively. Furthermore, 5.1% of 1947 female patients without MI and 9.9% of 1976 male patients without MI were above the manufacturer’s URL (female = 0.0136 ng/mL; male = 0.0198 mg/mL) but below 0.04 ng/mL. These results are lower than the false-positive rate of 12% observed in a separate study cited by the assay manufacturer. These data suggest that the manufacturer’s range is applicable to our patient population.

The association between chiropractors’ view of practice and patient encounter-level characteristics in Ontario, Canada: a cross-sectional study

Background Chiropractors have diverse views of practice, but the impact on their patient profiles and treatment approaches remains unclear. We assessed the association between chiropractors’ view of practice (unorthodox versus orthodox) and patient encounter-level characteristics among chiropractors who practice in Ontario, Canada. Methods We conducted a cross-sectional study using Ontario Chiropractic Observation and Analysis STudy (O-COAST) data. In O-COAST, Ontario chiropractors were randomly recruited from a list of registered chiropractors in 2015 and recorded up to 100 consecutive patient encounters. We classified chiropractors’ response regarding their views of practice as unorthodox when viewing “vertebral subluxation as an encumbrance to health that is corrected to benefit overall well-being”; other views were considered orthodox. Patient encounter-level characteristics included: (1) non-musculoskeletal reason-for-encounter; (2) subluxation as diagnosis; (3) duration of encounter (log-transformed for modeling); (4) unimodal manipulative treatment; and (5) patient health characteristics (good health status, some activity limitations). We conducted multilevel logistic regression to assess the association between view of practice and aforementioned characteristics, accounting for potential confounders and clustering of encounters within chiropractors. The multilevel models had two levels (level 1—patient encounter level; level 2—chiropractor level), with level 1 patient encounters nested within level 2 chiropractors. Results We included 40 chiropractors (mean age = 43.4 years, SD = 11.5) and 3,378 chiropractor-patient encounters. The 2,332 unique patients identified had a mean age of 48.5 years (SD = 18.5). Chiropractors with unorthodox views had higher odds of having patients with a non-musculoskeletal reason-for-encounter (adjusted odds ratio (aOR) 16.5, 95% CI 3.2–84.0) and subluxation as diagnosis (aOR 63.0, 95% CI 4.2–949.1). Encounters of chiropractors with unorthodox views were 0.6 times shorter than those with orthodox views (95% CI 0.4–0.9). Chiropractor level explained 32%, 75%, and 49% of the variability in non-musculoskeletal reason-for-encounter, subluxation as diagnosis, and encounter duration, respectively. We observed no association between unorthodox view and unimodal manipulative treatment or patient health characteristics. Conclusions Chiropractors’ unorthodox view of practice was associated with treating non-musculoskeletal conditions, subluxation as diagnosis, and shorter duration of encounter. Chiropractor level explained a high proportion of variability in these outcomes. Findings have implications for understanding chiropractic practice and informing interprofessional collaboration.

Facilitators and barriers for promoting healthy eating among primary care patients: results of a qualitative study among practice nurses

Background Practice nurses have an important role in promoting healthy eating to prevent or delay long-term complications from chronic lifestyle-related diseases. Objective To identify the facilitators and barriers encountered by practice nurses at a professional level when promoting healthy eating among patients. Methods Face-to-face semi-structured interviews were conducted with 21 Dutch practice nurses. Data were recorded, transcribed and analysed using inductive thematic analysis. Results Two main themes were determined: professional characteristics and professional–patient encounter. Professional characteristics included good communication skills and experience facilitated the successful promotion of healthy eating, while a lack of communication skills and lack of knowledge about diet were perceived as barriers. The most frequently identified facilitators for professional–patient encounter included ensuring a personal connection with patients, creating food awareness, focussing on small changes, adopting a tailored approach, motivating and arranging extra consultations. Barriers included lack of skills to raise the topic, lack of persistence, inability to find a common understanding, lack of competence in handling patients’ own choices and underuse of existing educational materials. Conclusions Further research using the identified facilitators and barriers for promoting healthy eating in primary care patients with chronic diseases could assist in the development of future training programmes for practice nurses.

Documentation of Prognostication Discussion

Background: Our organization is a NGO that provides palliative and supportive care at outpatient (OP), home visits and inpatient (IP), and Hospice settings. During patient encounter at different settings, documentation of discussion on prognostication was not done on the patients’ case sheets. This had created communication gap between the professionals, the patients and their family members. Due to this, there was a mismatch between the patients’ expectations and the services provided. Aims: The aim of the study was to implement A3 protocol and to increase the documentation status from zero to 75% by the end of five months after the commencement of the project. Settings and Design: OP - Department of Palliative Care Clinic A3 method. Material and Methods: The process map of the newly registered patients was followed. Root cause analysis was done using the Ishikawa Diagram. The main cause was that there was no specific format for documentation of prognostication. The professionals also felt some difficulty in disclosing the information as they were not following any prognostication tools upon which such discussions can be made. The key drivers were identified. Interventions were focused with specific contributors. A run chart was maintained to assess the progress of the interventions Statistical Analysis Used: Percentage calculation. Results: This endeavor has resulted in raising the documentation status from 0 to 80%. Conclusion: A3 protocol has been successful in developing the format for documentation of prognostication. Our team has gained confidence in implementing the A3 in other domains too.

Antimicrobial Prescription patterns in East Africa: A systematic Review

BackgroundAntimicrobial resistance is currently a recognised global health problem stemming from poor antibiotic stewardship by health workers and inappropriate antimicrobial use by patients. Data showing the extent of poor antimicrobial stewardship in low- and middle-income countries are scanty though high incidences of antimicrobial resistance are increasingly reported in many settings across the globe. The objective of the present study was, therefore, to evaluate prescriptions for antimicrobials in East Africa. MethodsA comprehensive literature search strategy that includes text words and medical subject headings was developed and applied to predefined electronic databases. Two authors independently screened the titles and abstracts of the outputs of the literature search. Full texts were then independently reviewed by the two researchers. Extracted data from included studies were pooled using meta-analysisResultsMajority of the included studies (30.8%) were retrieved from Ethiopia, followed by Sudan, Kenya and Tanzania each contributing 19.2%. The overall proportion of encounter with antimicrobials reported was 57% (95%CI 42%; 73%). Ethiopia had an overall patient encounter with antimicrobials of 63% [95%CI: 50%, 76%] followed by Sudan with an overall encounter with antimicrobials of 62% [95%CI: 34%, 85%]. Studies from Kenya reported the overall encounter with antimicrobials of 54% [95%CI: 15%, 90%], whereas studies from Tanzania reported an overall patient encounter with antimicrobials of 40% [95%CI: 21%, 60%]. ConclusionPrescription patterns demonstrated in this review significantly deviate from WHO recommendations suggesting inappropriate antimicrobial use in the East African countries. Further studies have to be pursued to generate more information on antimicrobial use in this region.

Ethical and Legal Issues

The sections of this chapter discuss both evaluation and management of legal and ethical aspects of the physician assistant (PA) profession, taking into consideration that the PA practice flows out of an interconnected relationship between the PA, the physician, and the patient. PAs are called to fulfill not only the law when practicing but also rise to uphold ethical principles. There are a variety of situations a provider can encounter throughout a career. Some topics are present in every patient encounter, such as confidentiality and informed consent. Some topics may only be present in certain cases, such as advanced directives and futile treatment. Nevertheless, the provider should be knowledgeable about each of these legal and ethical situations and understand the evaluation and management of them.