Mammography Screening: Evidence, History and Current Practice in Germany and Other European Countries

SUMMARY: In this review, we describe the history, evidence, and current practice of mammography screening in Europe and the newly implemented screening program in Germany. We report results of the first screening rounds in North Rhine-Westphalia and compare these with reference values set by the European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis. Finally, we summarize and compare performance indicators of the organized screening program in England, Italy, North Rhine-Westphalia and The Netherlands. Based on results of the first screening rounds, we conclude that the digital mammography screening program in North Rhine-Westphalia performs well and complies with the European guidelines. Besides relatively low attendance rates of approximately 53%, implementation of the German organized breast cancer screening program was successful.     

Diabetes empowerment scores among type 2 diabetes mellitus patients and its correlated factors: A cross-sectional study in a primary care setting in Malaysia

BACKGROUND There are limited studies on diabetes empowerment among type 2 diabetes patients, particularly in the primary care setting.AIM To assess the diabetes empowerment scores and its correlated factors among type2 diabetes patients in a primary care clinic in Malaysia.METHODS This is a cross sectional study involving 322 patients with type 2 diabetes mellitus(DM) followed up in a primary care clinic. Systematic sampling method was used for patient recruitment. The Diabetes Empowerment Scale(DES) questionnaire was used to measure patient empowerment. It consists of three domains:(1)Managing the psychosocial aspect of diabetes(9 items);(2) Assessing dissatisfaction and readiness to change(9 items); and(3) Setting and achieving diabetes goal(10 items). A score was considered high if it ranged from 100 to 140.Data analysis was performed using SPSS version 25 and multiple linear regressions was used to identify the predictors of total diabetes empowerment scores.RESULTS The median age of the study population was 55 years old. 56% were male and the mean duration of diabetes was 4 years. The total median score of the DES was 110 [interquartile range(IQR) = 10]. The median scores of the three subscales were 40 with(IQR = 4) for "Managing the psychosocial aspect of diabetes"; 36 with(IQR = 3) for "Assessing dissatisfaction and readiness to change"; and 34 with(IQR = 5) for "Setting and achieving diabetes goal". According to multiple linear regressions, factors that had significant correlation with higher empowerment scores among type 2 diabetes patients included an above secondary education level(P 0.001), diabetes education exposure(P = 0.003),lack of ischemic heart disease(P = 0.017), and lower glycated hemoglobin(HbA1 c) levels(P 0.001).CONCLUSION Diabetes empowerment scores were high among type 2 diabetes patients in this study population. Predictors for high empowerment scores included above secondary education level, diabetes education exposure, lack of ischemic heart disease status and lower HbA1 c.     

Knowledge and practice of foot care in Iranian people with type 2 diabetes

The aim of this study was to determine the knowledge and practice of foot care in people with type 2 diabetes. We carried out a cross-sectional study. A questionnaire was completed by 148 patients with type 2 diabetes in Tehran, Iran. Knowledge score was calculated and the current practice was determined. The mean knowledge score was 6.6 (standard deviation +/-3.0) out of a possible 16. Illiterate patients were the least knowledgeable (P= 0.008). Lack of adequate knowledge includes the following: 56% not aware of the effect of smoking on the circulation to the feet, 60% failed to inspect their feet and 42% did not know to trim their toenails. High risk practices including use of irritants to water (66.5%) and walking barefoot (62%). The results of this study highlight the patients' inadequate knowledge of self-care about their foot and lack of optimal podiatry service in Iran. These findings have implications for further evaluation, planning and management of patient care in diabetic foot disease.     

Patient attitudes about financial incentives for diabetes self-management:A survey

AIM:To study the acceptability of incentives for behavior changes in individuals with diabetes,comparing financial incentives to self-rewards and non-financial incentives.METHODS:A national online survey of United States adults with diabetes was conducted in March 2013(n = 153).This survey was designed for this study,with iterative testing and modifications in a pilot population.We measured the demographics of individuals,their interest in incentives,as well as the perceived challenge of diabetes self-management tasks,and expectations of incentives to improve diabetes self-management(financial,non-financial and self-rewards).Using an ordered logistic regression model,we assessed the association between a 32-point score of the perceived challenge of the self-management tasks and the three types of rewards.RESULTS:Ninety-six percent of individuals were interested in financial incentives,60% in non-financial incentives and 72% in self-rewards.Patients were less likely to use financial incentives when they perceived the behavior to be more challenging(odds ratio of using financial incentives of 0.82(95%CI:0.72-0.93) for each point of the behavior score).While the effectiveness of incentives may vary according to the perceived level of challenge of each behavior,participants did not expect to need large amounts to motivate them to modify their behavior.The expected average amounts needed to motivate a 5 lb weight loss in our population and to maintain this weight change for a year was $258(interquartile range of $10-100) and $713(interquartile range of $25-250) for a 15 lb weight loss.The difference in mean amount estimates for 5 lb and 15 lb weight loss was significant(P 0.001).CONCLUSION:Individuals with diabetes are willing to consider financial incentives to improve diabetes selfmanagement.Future studies are needed to explore incentive programs and their effectiveness for diabetes.     

Disease management in chronic kidney disease

Chronic kidney disease (CKD) is a growing health problem of epidemic proportions both in the United States and worldwide. The care of CKD patients, before and after starting dialysis, remains highly fragmented resulting in suboptimal clinical outcomes and high costs, creating a high burden of disease on patients and the health care system. Disease management (DM) is an approach to coordinating care for this complex population of patients that has the promise of improving outcomes and constraining costs. For CKD patients not yet on dialysis, the major goals of a DM program are (1) early identification of CKD patients and therapy to slow the progression of CKD, (2) identification and management of the complications of CKD per se, (3) identification and management of the complications of comorbid conditions, and (4) smooth transition to renal replacement therapy. For those CKD patients on dialysis, focused attention on avoidable hospitalizations is a key to a successful DM program. Multidisciplinary collaboration among physicians (nephrologist, primary care physician, cardiologist, endocrinologist, vascular surgeons, and transplant physicians) and participating caregivers (nurse, pharmacist, social worker, and dietician) is critical as well. There are several potential barriers to the successful implementation of a CKD/end-stage renal disease DM program, including lack of awareness of the disease state among patients and health care providers, late identification and referrals to a nephrologist, complex fragmented care delivered by multiple providers in many different sites of care, and reimbursement that does not align incentives for all involved. Recent experience suggests that these barriers can be overcome, with DM becoming a promising approach for improving outcomes for this vulnerable population.     

The Psychology of Bariatric Surgery Patients: A Clinical Report

Our discussion focuses on theoretical and applied considerations for psychological care of the morbidly obese patient presenting for surgical correction of this refractory condition. Observations are gleaned from a biomedical literature review and our clinical experiences in the design and implementation of the psychological component in our extant multidisciplinary bariatric surgery program at Universal Medical Center, Plantation, Florida. The clinical sample includes 401 patients receiving vertical banded gastroplasty, Roux-en-Y gastric bypass and silastic ring gastroplasty from September of 1986 to May of 1994. Beyond a consideration of the psychological sequelae of depression, anxiety and addictions, we discuss the specific impact of psychosocial stress and implications of the morbid obesity archetype, with particular emphasis on iratrogenic medical stereotype. Owing to the nature of this report, and the literature review, our impressions are anecdotal and clinical. However, when considered against the underserved and misconceived needs of the morbidly obese patient, we propose that a comprehensive multidisciplinary program incorporating psychological service is not only of critical benefit in enhancing patient co-operation, but also in securing patients' dramatic quality of life change. Recommendations for future research and the development of standardized psychological care models for the morbidly obese patient conclude the discussion.     

Competences for self-care and self-control in diabetes mellitus type 2 in primary health care

The purpose of the guidelines of self-care and self-control of type 2 diabetes mellitus proposed by the Brazilian Ministry of Health is to strengthen and qualify users and health care professionals through the integrality and longitudinality of care with this disease. This article aims to present the self-care and self-control of people with type 2 diabetes mellitus in objective terms, taking into account the current recommen-dations based on scientific evidence and also from the subjective point of view, that is, emphasizing the aspects related to experience and subjectivity of these people. Next, we present the essential skills for self-care and self-control of users and professionals working in primary health care.     

Models of care for co‐morbid diabetes and chronic kidney disease

Diabetes and chronic kidney disease (CKD) are two of the most prevalent co‐morbid chronic diseases in Australia. The increasing complexity of multi‐morbidity, and current gaps in health‐care delivery for people with co‐morbid diabetes and CKD, emphasize the need for better models of care for this population. Previously, proposed published models of care for co‐morbid diabetes and CKD have not been co‐designed with stake‐holders or formally evaluated. Particular components of health‐care shown to be effective in this population are interventions that: are structured, intensive and multifaceted (treating diabetes and multiple cardiovascular risk factors); involve multiple medical disciplines; improve self‐management by the patient; and upskill primary health‐care. Here we present an integrated patient‐centred model of health‐care delivery incorporating these components and co‐designed with key stake‐holders including specialist health professionals, general practitioners and Diabetes and Kidney Health Australia. The development of the model of care was informed by focus groups of patients and health‐professionals; and semi‐structured interviews of care‐givers and health professionals. Other distinctives of this model of care are routine screening for psychological morbidity; patient‐support through a phone advice line; and focused primary health‐care support in the management of diabetes and CKD. Additionally, the model of care integrates with the patient‐centred health‐care home currently being rolled out by the Australian Department of Health. This model of care will be evaluated after implementation across two tertiary health services and their primary care catchment areas.     

Diabetes self-care in primary health facilities in India-challenges and the way forward

India has approximately 73 million people living with diabetes and another 37 million with prediabetes while nearly 47% of the diabetes cases are undiagnosed.The high burden of poor glycemic control and early onset of complications with associated economic costs indicates a high prevalence of poor self-management practices. It is well-established that achieving patient-centered primary care consistent with a chronic care model ensures optimum diabetes self-management support and improves long-term clinical and health outcomes in diabetes patients. The public sector primary care system in India provides services free of cost to beneficiaries but lacks patient-centered care that undermines diabetes selfmanagement education and support. Furthermore, factors like poor patient knowledge of diabetes, suboptimal medication adherence, persistent clinical inertia, lack of data for monitoring and evaluation through clinical audit worsens the standards of diabetes care in primary care settings of India. There is a need for government initiatives to be directed towards the provision of comprehensive outpatient care that is inclusive of uninterrupted supply of drugs, provision of essential laboratory investigators, training and availability of qualified diabetes educators and availability of specialist support when required. Furthermore, the integration of depression screening and smoking cessation services at the primary care level is warranted.     

Management of critically ill patients with type 2 diabetes:The need for personalised therapy

Critical illness in patients with pre-existing diabetes frequently causes deterioration in glycaemic control.Despite the prevalence of diabetes in patients admitted to hospital and intensive care units,the ideal management of hyperglycaemia in these groups is uncertain.There are data that suggest that acute hyperglycaemia in critically ill patients without diabetes is associated with increased mortality and morbidity.Exogenous insulin to keep blood glucose concentrations 10 mmol/L is accepted as standard of care in this group.However,preliminary data have recently been reported that suggest that chronic hyperglycaemia may result in conditioning,which protects these patients against damage mediated by acute hyperglycaemia.Furthermore,acute glucose-lowering to 10 mmol/L in patients with diabetes with inadequate glycaemic control prior to their critical illness appears to have the capacity to cause harm.This review focuses on glycaemic control in critically ill patients with type 2 diabetes,the potential for harm from glucose-lowering and the rationale for personalised therapy.     

Alphabet strategy for diabetes care: A checklist approach in the time of COVID-19 and beyond

Chronic disease management requires achievement of critical individualised targets to mitigate again long-term morbidity and premature mortality associated with diabetes mellitus. The responsibility for this lies with both the patient and health care professionals. Care plans have been introduced in many healthcare settings to provide a patient-centred approach that is both evidence-based to deliver positive clinical outcomes and allow individualised care. The Alphabet strategy (AS) for diabetes is based around such a care plan and has been evidenced to deliver high clinical standards in both well-resourced and under-resourced settings. Additional patient educational resources include special care plans for those people with diabetes undertaking fasting during Ramadan, Preconception Care, Prevention and Remission of Diabetes. The Strategy and Care Plan has facilitated evidence-based, cost-efficient multifactorial intervention with an improvement in the National Diabetes Audit targets for blood pressure, cholesterol levels and glycated haemoglobin. Many of these attainments were of the standard seen in intensively treated cohorts of key randomized controlled trials in diabetes care such as the Steno-2 and United Kingdom Prospective Diabetes Study. This is despite working in a relatively under-resourced service within the United Kingdom National Health Service. The AS for diabetes care is a useful tool to consider for planning care, education of people with diabetes and healthcare professional. During the time of the coronavirus disease 2019 pandemic the risk factors for the increased mortality observed have to be addressed aggressively. The AS has the potential to help with this aspiration.     

社区护理干预对糖尿病患者遵医行为及血糖控制情况的影响分析

目的：探讨社区护理干预对糖尿病患者遵医行为及血糖控制情况的影响。方法选取2012年11月~2013年11月本院收治的糖尿病患者75例进行研究,随机分为两组,均常规服用降糖药物,对照组37例实施常规的健康教育及护理,观察组38例在常规健康教育及护理的基础上实施社区护理干预,比较两组遵医率、出院时及随访结束血糖控制情况。结果观察组复查、饮食、服药、自我监测及运动的遵医率与对照组比较较高（P＜0.05）。两组随访结束时空腹血糖及餐后2h血糖均低于出院时,但是观察组差异有统计学意义（P＜0.05）,随访结束时观察组空腹血糖及餐后2h血糖均低于对照组（P＜0.05）。结论社区护理干预能使糖尿病患者的遵医率提高,控制血糖效果较好,可以推广应用。     

Private Bundles: The Nuances of Contracting and Managing Total Joint Arthroplasty Episodes

In recent years, bundled payment reimbursement models have been used to address the unsustainable rising cost of healthcare. Centers for Medicare and Medicaid Services initiatives, such as Bundled Payment for Care Improvement Program, have already demonstrated their ability to create financial and performance accountability in the public sector. More recently, these value-based models have been introduced among private payers to increase coordination, quality, and efficiency. Bundled payment strategies provide incentives for physicians and healthcare professionals to eliminate unnecessary services and reduce costs. This article discusses our experience at a private institution with transitioning to a bundled payment program, while identifying the challenges and strategies associated with a successful implementation.     

Effective management of patients with diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team

A longitudinal observational study on a convenience sample was conducted between 4 January and 31 December of 2010 to evaluate clinical outcomes that occur when a new Interprofessional Diabetes Foot Ulcer Team (IPDFUT) helps in the management of diabetes‐related foot ulcers (DFUs) in patients living in a small urban community in Ontario, Canada. Eighty‐three patients presented to the IPDFUT with 114 DFUs of average duration of 19·5 ± 2·7 weeks. Patients were 58·4 ± 1·4 years of age and 90% had type 2 diabetes, HbA1c of 8·3 ± 2·0%, with an average diabetes duration of 22·3 ± 3·4 years; in 69% of patients, 78 DFUs healed in an average duration of 7·4 ± 0·7 weeks, requiring an average of 3·8 clinic visits. Amputation of a toe led to healing in three patients (4%) and one patient required a below‐knee amputation. Six patients died and three withdrew. Adding a skilled IPDFUT that is trained to work together resulted in improved healing outcomes. The rate of healing, proportion of wounds closed and complication rate were similar if not better than the results published previously in Canada and around the world. The IPDFUT appears to be a successful model of care and could be used as a template to provide effective community care to the patients with DFU in Ontario, Canada.     

Quality of care indicators for prostate cancer: Progress toward consensus

Previously-documented variations in patterns of care and patient outcomes suggest differences in the quality of care provided to men with prostate cancer. Herein we describe ongoing efforts to measure the quality of prostate cancer care, including the development and pilot-testing of the RAND prostate cancer quality indicators and the selection of the consensus-based Physician Performance Measurement Set for Prostate Cancer. We also summarize current payer-led initiatives aimed at measuring quality of care for men with prostate cancer. We conclude that currently-available prostate cancer quality indicators are derived from valid, consensus-based methodologies and capture clinical practices that are necessary for high-quality care in early-stage prostate cancer. Despite this promise, however, the currently available measures have several limitations that should be considered during their implementation in prostate cancer quality assessment and improvement activities.     

Three components of education in burn care: surgical education, inter-professional education, and mentorship

Education in burn care can be divided into three main components: surgical education, inter-professional education, e.g. critical care education and mentorship. To date these components have been used in varying degrees in most health institutions and to even lesser extent in burn care. The aim of this paper is to highlight each component and how these have been utilized in other fields to develop teams and foster education, and how they can be translated for burn teams. These ideas are not novel; however, this paper aims to shed light on how these concepts can be implemented in burn care, thus not only improving education, but also enabling recruitment and retention of health care providers in this field.     

Does the implementation of a clinical information system decrease the time intensive care nurses spend on documentation of care?

BACKGROUND: The number of intensive care units (ICU) using a clinical information system (CIS) is increasing. It is believed that replacing manual charting with an automatic documentation system allocates nurses more time for patient care. The objective of this study was to measure changes in nurses' working time utilization after the implementation of a CIS in a polyvalent ICU of a large Finnish central hospital. METHODS: An activity analysis-based comparison of the ICU nurses' working time utilization before and after the implementation of a CIS. RESULTS: After the implementation of a CIS the total time the nurses spent on documentation of nursing care increased by 3.6% (NS), 15 min per shift of 8 h per nurse. The total time they spent on patient care increased by 5.5% (P < 0.05), 21 min. Intensive care nursing activities increased by 3.7% (P < 0.05), 14 min. The length of the nurses' ICU experience had some effect on these figures. The demand for nurse labor remained constant. CONCLUSIONS: After the implementation of a CIS, an increase in the time nurses spent on documentation of care was detected, which suggests a need for further development of the system. As all the measured time changes were relatively small, any plans to reduce the ICU staff number with the aid of computers were not justified.     

Using the intensive care unit to teach end-of-life skills to rotating junior residents

Background

This study tested the effectiveness and perceived value of a palliative/end-of-life (P/EOL) curriculum for junior residents implemented during an intensive care unit (ICU) rotation.

Methods

Residents rotating through the ICU over a 6-month period completed pre- and post-curriculum surveys evaluating their self-assessed efficacy in providing P/EOL care and attitudes towards P/EOL care. Scores were analyzed using a paired Student t test.

Results

Seventeen of 19 (90%) residents completed both the pre- and post-curriculum evaluations. The P/EOL curriculum increased self-assessed efficacy ratings in the domains of pain management (P = .04), psychosocial knowledge (P = .001), communicator knowledge (P = .001), professional knowledge (P = .002), and manager knowledge (P < .001). The rotation was rated as being valuable in preparing residents to care for patients near the end-of-life (P < .05), with surgery residents indicating it to be the most valuable rotation in their training program for learning about P/EOL care.

Conclusions

An ICU P/EOL curriculum improves self-assessed efficacy scores across multiple domains in P/EOL care and is seen as a valuable educational experience.     

The next stage in the health care economy: aligning the interests of patients,providers, and third-party payers through consumer-driven health care plans

This article reviews employers' attempts over the past 25 years to address the cost and accessibility of health care services for their employees and the effect these efforts have had on U.S. health care delivery. The difficulties in aligning the interests of all parties in a third-party health beneficiary contract are examined. Many employers are considering consumer-driven health care plans as an alternative to managed care plans to both control health care costs and improve employee satisfaction. Such plans differ from fee-for-service and managed care models in terms of the economic alignment of the parties. Consumer-driven plans align the employer's economic interest with the employee/patient, and reduce health benefit costs by providing information, tools, and direct economic incentives to employees for self-management of health care dollars. Because these incentives are designed to reduce the consumption of services, providers are the party left out of economic alignment under the consumer-driven model.     

Successful treatment of Pseudomonas peritonitis during continuous ambulatory peritoneal dialysis

Successful eradication of Pseudomonas peritonitis is described in 12 (57%) of 21 cases from a large continuous ambulatory peritoneal dialysis (CAPD) program at a tertiary care center. In successful cases, cure was achieved within 17 days using therapy which included aminoglycoside started routinely at the onset of symptoms and an antipseudomonal penicillin or cephalosporin derivative added as soon as pseudomonas infection was identified on culture. Of the 9 treatment failures which required catheter removal, 2 had failure of peritoneal drainage, 4 had infection with multiple and/or drug-resistant Pseudomonas strains, and 3 had persistent catheter tunnel infection which resulted in recurrent Pseudomonas peritonitis. Factors such as diabetes mellitus and pediatric age group did not prevent successful medical therapy. Predisposing factors favoring development of Pseudomonas peritonitis included technical failures and in a few cases recent antibiotic therapy. We conclude that Pseudomonas peritonitis complicating CAPD can be successfully cured without catheter removal or discontinuation of CAPD in many cases, particularly when complicating factors are not present.