Argumentation logic for the flexible enactment of goal-based medical guidelines

RESEARCH PURPOSE: We have designed a prototype clinical workflow system that allows the specification and enactment of medical guidelines in terms of clinical goals to be achieved, maintained or avoided depending on the patient's disease and treatment evolution. The prototype includes: (1) an argumentation-based decision support system which can be used both to represent medical decisions within guidelines, and to dynamically choose the most suitable plans to achieve clinical goals, and (2) mechanisms to specify a health organization's facilities and health workers skills and roles, which can be taken into account during the decision process in order to improve quality of care. RESULTS: The framework has been fully implemented in the COGENT formal modeling system. The prototype has been evaluated implementing a hypertension guideline. CONCLUSIONS: The framework has shown flexibility and adaptability in (1) advising and tailoring health care based on a health organization's resources and a patient's particular medical condition, (2) delegating health care, and (3) replanning when unexpected situations arise.     

Psychosocial stress and cardiovascular disease. Part 3: Clinical and policy implications of research on the transcendental meditation program

Cardiovascular disease (CVD) remains the leading cause of death in the United States today and a major contributor to total health care costs. Psychosocial stress has been implicated in CVD, and psychosocial approaches to primary and secondary prevention are gaining research support. This third article in the series on psychosocial stress and CVD continues the evaluation of one such approach, the Maharishi Transcendental Meditation program, a psychophysiological approach from the Vedic tradition that is systematically taught by qualified teachers throughout the world. Evidence suggests not only that this program can provide benefits in prevention but also that it may reduce CVD-related and other health care expenses. On the basis of data from the studies available to date, the Transcendental Meditation program may be responsible for reductions of 80% or greater in medical insurance claims and payments to physicians. This article evaluates the implications of research on the Transcendental Meditation program for health care policy and for large-scale clinical implementation of the program. The Transcendental Meditation program can be used by individuals of any ethnic or cultural background, and compliance with the practice regimen is generally high. The main steps necessary for wider adoption appear to be: (1) educating health care providers and patients about the nature and expected benefits of the program, and (2) adjustments in public policies at the state and national levels to allow this program to be included in private and public health insurance plans.     

Ventilator-associated pneumonia: diagnosis, treatment, and prevention

While critically ill patients experience a life-threatening illness, they commonly contract ventilator-associated pneumonia. This nosocomial infection increases morbidity and likely mortality as well as the cost of health care. This article reviews the literature with regard to diagnosis, treatment, and prevention. It provides conclusions that can be implemented in practice as well as an algorithm for the bedside clinician and also focuses on the controversies with regard to diagnostic tools and approaches, treatment plans, and prevention strategies.     

Acceptable regret in medical decision making

When faced with medical decisions involving uncertain outcomes, the principles of decision theory hold that we should select the option with the highest expected utility to maximize health over time. Whether a decision proves right or wrong can be learned only in retrospect, when it may become apparent that another course of action would have been preferable. This realization may bring a sense of loss, or regret. When anticipated regret is compelling, a decision maker may choose to violate expected utility theory to avoid regret. We formulate a concept of acceptable regret in medical decision making that explicitly introduces the patient's attitude toward loss of health due to a mistaken decision into decision making. In most cases, minimizing expected regret results in the same decision as maximizing expected utility. However, when acceptable regret is taken into consideration, the threshold probability below which we can comfortably withhold treatment is a function only of the net benefit of the treatment, and the threshold probability above which we can comfortably administer the treatment depends only on the magnitude of the risks associated with the therapy. By considering acceptable regret, we develop new conceptual relations that can help decide whether treatment should be withheld or administered, especially when the diagnosis is uncertain. This may be particularly beneficial in deciding what constitutes futile medical care.     

Liaison psychiatry in general practice: a comparison of the liaison-attachment scheme and shifted outpatient clinic models.

Most psychiatrists who visit health centres use the shifted outpatient clinic model, the main aim of which is to improve secondary care by providing it in the primary care setting. For five years we have employed a liaison-attachment scheme in which support and advice from the psychiatrist enables general practitioners to improve their care of patients with psychiatric and psychological problems. One of the advantages of the latter model is that the psychiatrist can contribute to the care of patients not seen by the specialist psychiatric service and also to the development of the primary care team. The scheme is cost effective as psychiatrists can advise on the care of far more patients than they could see in formal referrals, fewer patients are taken on for a course of psychiatric treatment that could be provided by general practitioners and the skills of general practitioners and their trainees are enhanced. It is hoped that more general practitioners will adopt this pattern of working so that it can be fully developed and evaluated.     

Labelling chronic illness in primary care: a good or a bad thing?

Traditionally the management of any chronic condition starts with its diagnosis. The labelling of disease can be beneficial in terms of defining appropriate treatment such as in coronary artery disease. However, sometimes it may be detrimental such as when x-rays are used to diagnose lumbar spondylosis leading to patients inappropriately limiting their activity. Chronic knee pain in the elderly is another example where applying labels is problematical. A common diagnosis in this situation is osteoarthritis, but this label can be applied in two ways: as a radiological diagnosis, or as a clinical one. The x-ray diagnosis, however, does not equate with the clinical syndrome, and vice versa. In addition, diagnosing knee pain as osteoarthritis does not necessarily help in management, since a patient's debility is more dependent upon their clinical signs and symptoms than the presence of radiographic osteoarthritis, and by the same token its clinical counterpart. GPs are consistent in their management of knee pain, but in attempting to diagnose the pain as osteoarthritis, these plans can alter and become more dependent on the actual diagnosis than the clinical picture. As a result management may well diverge from what the current best evidence supports. Diagnosis for diagnosis sake, should therefore be discouraged, and chronic knee pain gives us one example of why this is the case. GPs would be better placed to manage this condition if it was considered more as a regional pain syndrome, perhaps defining it simply as 'chronic knee pain in older people'. This example suggests that there is a pressing need in primary care to carefully consider in chronic disease when it is appropriate to be definitive in diagnosis such that when using disease specific labels, there is definite benefit for the patient and doctor.     

HIV clinical trials in correctional settings: right or retrogression?

The right of incarcerated prison and jail inmates to health care is protected by the 8th and the 14th amendments of the Constitution, respectively. Does the right to health care include access to clinical trials? At the time of this writing, clinical trials have become part of the fabric of HIV/AIDS care, allowing patients to participate in studies of new and often lifesaving treatments. Participation in trials can also be dangerous, as illustrated by the recent death of a subject in a gene therapy trial. This danger is compounded by ethical dilemmas that can arise from the large amount of financial support for clinical trials (greater than 75%) that is derived from for-profit corporations. Indeed, clinical trials are the subject of grave concern on the part of the United States Government, which has recently taken steps to shore up human subject safeguards. Following a conference on the conduct of clinical trials in correctional settings, the Office for Human Research Protections suspended prison research conducted by 4 prestigious academic institutions.     

Use of health information technology (HIT) to improve statin adherence and low-density lipoprotein cholesterol goal attainment in high-risk patients: Proceedings from a workshop

The workshop discussions focused on how low-density lipoprotein cholesterol (LDL-C) goal attainment can be enhanced with the use of health information technology (HIT) in different clinical settings. A gap is acknowledged in LDL-C goal attainment, but because of the passage of the American Recovery & Reinvestment Act and the Health Information Technology for Economic and Clinical Health Acts there is now reason for optimism that this gap can be narrowed. For HIT to be effectively used to achieve treatment goals, it must be implemented in a setting in which the health care team is fully committed to achieving these goals. Implementation of HIT alone has not resulted in reducing the gap. It is critical to build an effective management strategy into the HIT platform without increasing the overall work/time burden on staff. By enhancing communication between the health care team and the patient, more timely adjustments to treatment plans can be made with greater opportunity for LDL-C goal attainment and improved efficiency in the long run. Patients would be encouraged to take a more active role. Support tools are available. The National Lipid Association has developed a toolkit designed to improve patient compliance and could be modified for use in an HIT system. The importance of a collaborative approach between nongovernmental organizations such as the National Lipid Association, National Quality Forum, HIT partners, and other members of the health care industry offers the best opportunity for long-term success and the real possibility that such efforts could be applied to other chronic conditions, for example, diabetes and hypertension.     

Interface between biomedical and traditional systems of treatment and care among HIV positive fisher folk in two fishing communities on Lake Victoria,Uganda

BackgroundFisherfolk have been identified as a key population in the HIV response in Uganda due to high HIV prevalence and low engagement in HIV services. While studies have examined lifestyles and risk, much remains to be understood about help and health seeking experiences, including the combined use of biomedical and traditional health care.ObjectiveTo examine the use of biomedical and traditional health care in two fishing communities around Lake Victoria in Uganda.MethodsExploratory, in-depth qualitative study involving semi-structured interviews with 42 HIV positive fisherfolk.ResultsPrior to HIV diagnosis, participants who described becoming ill sought different forms of help including biomedical treatment prescribed by health workers or self-prescribed; biomedical and herbal medicines together; herbal medicines only; or no form of treatment. Following HIV diagnosis, the majority of participants used ART exclusively, while a smaller number used both ART and traditional care strategies, or reported times when they used alternative therapies instead of ART. Prior to HIV diagnosis, fisherfolk''s health care seeking practices inhibited engagement with HIV testing and access to biomedical HIV treatment and care. After HIV diagnosis, most resorted only to using ART.ConclusionStudy findings provide insight into how fisherfolk''s use of biomedical and traditional care prior to diagnosis influences subsequent engagement with HIV treatment. Efforts are needed to reach fisherfolk through everyday health seeking networks to ensure HIV is diagnosed and treated as early as possible.     

An Internet Tool for Creation of Cancer Survivorship Care Plans for Survivors and Health Care Providers: Design,Implementation, Use and User Satisfaction

Background

Survivorship care plans have been recommended by the Institute of Medicine for all cancer survivors. We implemented an Internet-based tool for creation of individualized survivorship care plans. To our knowledge, this is the first tool of this type to be designed and made publicly accessible.

Objective

To investigate patterns of use and satisfaction with an Internet-based tool for creation of survivorship care plans.

Methods

OncoLife, an Internet-based program for creation of survivorship care plans, was designed by a team of dedicated oncology nurses and physicians at the University of Pennsylvania. The program was designed to provide individualized, comprehensive health care recommendations to users responding to queries regarding demographics, diagnosis, and cancer treatments. After being piloted to test populations, OncoLife was made publicly accessible via Oncolink, a cancer information website based at the University of Pennsylvania which averages 3.9 million page views and over 385,000 unique visits per month. Data entered by anonymous public users was maintained and analyzed.

Results

From May 2007 to November 2008, 3343 individuals utilized this tool. Most (63%) identified themselves as survivors, but also health care providers (25%) and friends/family of survivors (12%). Median age at diagnosis was 48 years (18 - 100+), and median current age 51 (19 - 100+). Most users were Caucasian (87%), female (71%), and college-educated (82%). Breast cancer was the most common diagnosis (46%), followed by hematologic (12%), gastrointestinal (11%), gynecologic (9%), and genitourinary (8%). Of all users, 84% had undergone surgery, 80% chemotherapy, and 60% radiotherapy. Half of users (53%) reported receiving follow-up care from only an oncologist, 13% only a primary care provider (PCP), and 32% both; 12% reported having received survivorship information previously. Over 90% of users, both survivors and health care providers, reported satisfaction levels of “good” to “excellent” using this tool.

Conclusions

Based on our experience with implementation of what is, to our knowledge, the first Web-based program for creation of survivorship care plans, survivors and health care providers appear both willing to use this type of tool and satisfied with the information provided. Most users have never before received survivorship information. Future iterations will focus on expanding accessibility and improving understanding of the needs of cancer survivors in the era of the Internet.     

The U.S. health care system: challenges for the academic health professions community.

The author discusses the need to create structural reforms in the nation's health care system, built around a consensus on workable, affordable solutions, the first of four needs in this area, and presents a set of principles that must frame the debate on health care reform (e.g., that health care must be accessible to all Americans). He also presents practical options that address the United States' most urgent health care concerns (e.g., making the cost of health insurance more affordable for small businesses). The second need is to preserve and strengthen the nation's biomedical research enterprise; the author outlines steps that are already under way to deal with this need (e.g., the development of a Biomedical Research Initiative in the Public Health Service and the allocation of funds for various research-connected activities). The third need is to increase the participation of minority youth in science and the health professions; the author outlines steps that are being taken to encourage such participation (e.g., helping historically black colleges and universities and funding training programs for training minority professionals in health care). The last need discussed is to foster a culture of character: empowering citizens to take control of their own lives to eliminate costly debilitating illness before it strikes. For all these needs to be addressed successfully, it is crucial that the involvement of the academic health professions community and the community at large be expanded.     

Perceptions of asthma in South Asians and their views on educational materials and self-management plans: a qualitative study

Asians with asthma have higher hospital admission rates than whites without any evidence of increased asthma severity. There is limited information as to whether these differences are due to language or communication difficulties, variable knowledge and cultural attitudes to asthma or deficiencies of medical care. A qualitative study with 60 participants (12 participants with asthma for semi-structured interviews and 48 participants for focus groups) was designed to explore knowledge about asthma, attitudes, perceptions, health beliefs and health needs of those from Pakistan and India (South Asians). Overall, most of the patients with asthma were aware of the symptoms and trigger factors of asthma and were well informed about the 'reliever' and 'preventer' properties of their inhalers. They were also well informed about alternative/complementary therapies and were willing to try them should the treatment provided by their general practitioner (GP) fail to resolve their symptoms. Most were dissatisfied with the asthma care provided by their GPs e.g. delays in making the diagnosis and deficiencies in providing both verbal and written information on asthma. There was lack of awareness about self-management plans although when explained, the concept of self management was well received and there was approval for the concept of written action plans. All the focus group participants seemed to know something about asthma and amongst those with the condition (or with relatives with the condition), knowledge of the disease and its treatment seemed to be good. It was concluded that improved dissemination of written and verbal information on all aspects of asthma and increased awareness, training and support for adoption of written self-management (action) plans is needed to provide a more efficient and effective service for South Asian patients with asthma.     

Cancer control policy in Australia

Australia has an evolving national cancer control agenda. In this paper, we review the history and development of cancer control policies in Australia up to the end of 2005, and discuss the principal publications produced by both government and non-government groups which have given rise to cancer control recommendations, goals and targets. These cancer control plans have arisen in response to the impact of cancer on the Australian community and in recognition of the health gains that can be made through effective cancer control. They have been developed either in the context of a broader framework of health policy or as specific endeavours in regard to cancer. The specific recommendations and strategies proposed have focused on reducing the impact of cancer in the Australian population. Most commonly, recommendations, goals, and targets within the cancer control plans have addressed points along the continuum of care, specific cancers, and frameworks and processes. The strength of these reports is their comprehensive approach in identifying priority cancers and areas where specific developments should impact on morbidity and mortality. In the future, cancer control plans should be better supported by economic evaluations, and greater financial support for implementation and regular assessment is needed to identify progress on cancer outcomes. The more recent national and State cancer control plans include the development of frameworks to foster a coordinated and cohesive approach to the delivery of cancer care. These plans represent important reforms in cancer care in Australia, and have the potential to reduce the impact of cancer on the community and improve health outcomes.     

Mental health intervention programs in primary care: their scientific basis.

This study examines the scientific basis for mental health intervention programs in primary care. The validity of five underlying assumptions is evaluated, using the results of a naturalistic study covering a representative sample of 25 Dutch family practices and data from the literature. Our findings corroborate the validity of the assumptions. Firstly, our study indicates that mental disorders are indeed very prevalent in primary care settings. Secondly, we find that a substantial proportion of mental disorders is not recognized by the general practitioner (GP). Thirdly, our data show that mental disorders in primary care are not transient or self-limiting. Fourthly, it is shown that only half of the GP attenders with a mental disorder receive some form of mental health treatment in the 14 months after their index consultation. Finally, our data suggest that mental disorders, when identified, can be treated effectively in primary care. These findings are in general agreement with the literature. In the discussion we underscore the need for public health intervention programs targeted at primary care providers. Training programs for general physicians must be directed at improving recognition and diagnosis and at enhancing the availability and quality of mental health interventions. The effectiveness of these programs has to be tested in randomized trials.     

Clinical immunology in practice, new opportunities

While research provides new opportunities for diagnosing and treating patients with allergic and immunological disorders, there are significant challenges to putting these advances into use in clinical practice. Each new test may require clinicians in private practice to battle with a health insurer's designated clinical laboratory in an effort to get this new test and other accurate immunological laboratory studies. A new test may or may not be covered by some health care plans and may or may not be available from their designated laboratories. Many of these laboratories send time-sensitive samples across the country with risk of time delays and poor specimen handling leading to inaccurate results and/or the need to send repeat specimens. The growing role of managed care in every medical decision has led to frustrations for the patient and physician. This frequently requires a consult at a tertiary care center, where laboratory studies may be more easily accessible with fewer restrictions. Where are the new opportunities? Some are found in the enhanced ability to make intelligent decisions in the diagnosis and treatment of immunological diseases. There is now a greater selection and availability of intravenous γ-globulin (IVIG), that can be matched to individual patient needs. The appropriate selection of these products will decrease adverse reactions and increase safety. There was a major advance in the treatment of moderate and severe asthma with the addition of omalizumab therapy. It provides allergists and immunologists with their first monoclonal humanized anti-IgE antibody.     

Cost-effective infertility care

Cost-effective healthcare has become a principal paradigm in all areas of medicine. In order to establish cost-effective care, clinical outcomes under various cost conditions have to be examined. Such a process cannot be static since it has to consider ever evolving treatments and outcome results. In infertility, the evaluation of cost-effective care should be simpler than in most other areas of medicine since treatment end-points are easily defined. Nevertheless, the field is lagging in the establishment of cost-effective treatment algorithms. In this review, an effort is made to define the current state of the art of cost effective infertility care, to suggest steps that can be taken to drive the process forward and to encourage the introduction of even limited processes to further the concept of outcome-dependent cost assessment within a practice setting. The limited availability of resources mandates their judicious use throughout medicine. In a field like infertility, by many (rightly or wrongly) perceived as 'elective', the judicious use of resources seems even more necessary since it would permit the treatment of larger patient populations than have currently access to care without further expense to third-party payments.     

Mental health diagnosis by nurses using the Global Mental Health Assessment Tool: a validity and feasibility study.

BACKGROUND: The Global Mental Health Assessment Tool-Primary Care Version (GMHAT/PC) has been developed to assist health professionals to make a quick and comprehensive standardised mental health assessment. It has proved to be a reliable and valid tool in a previous study involving GPs. Its use by other health professionals may help in detecting and managing mental disorders in primary care and general health settings. AIM: To assess the feasibility of using a computer-assisted diagnostic interview by nurses and to examine the level of agreement between the GMHAT/PC diagnosis and psychiatrists' clinical diagnosis. DESIGN OF STUDY: Cross-sectional validation study. SETTING: Primary care, general healthcare (cardiac rehabilitation clinic), and community mental healthcare settings. METHOD: A total of 215 patients between the ages of 16 and 75 years were assessed by nurses and psychiatrists in various settings: primary care centre (n = 54), cardiac rehabilitation centre (n = 98), and community mental health clinic (n = 63). The time taken for the interview, and feedback from patients and interviewers were indicators of feasibility, and the kappa coefficient (kappa), sensitivity, and specificity of the GMHAT/PC diagnosis were measures of validity. RESULTS: Mean duration of interview was under 15 minutes. The agreement between nurses' GMHAT/PC interview-based diagnosis and psychiatrists' International Classification of Diseases (ICD)-10 criteria-based clinical diagnosis was 80% (kappa = 0.76, sensitivity = 0.84, specificity = 0.92). CONCLUSION: The GMHAT/PC can assist nurses to make accurate mental health assessment and diagnosis in various healthcare settings and it is acceptable to patients.     

Consumer-Choice Health plan (second of two parts). A national-health-insurance proposal based on regulated competition in the private sector.

Medical costs are straining public finances. Direct economic regulation will raise costs, retard beneficial innovation and be increasingly burdensome to physicians. As an alternative, I suggest that the government change financial incentives by creating a system of competing health plans in which physicians and consumers can benefit from using resources wisely. Main proposals consist of changed tax laws, Medicare and Medicaid to subsidize individual premium payments by an amount based on financial and predicted medical need, as well as subsidies usable only for premiums in qualified health insurance or delivery plans operating under rules that include periodic open enrollment, community rating by actuarial category, premium rating by market area and a limit on each person's out-of pocket costs. Also, efficient systems should be allowed to pass on the full savings to consumers. Finally, incremental changes should be made in the present system to alter it fundamentally, but gradually and voluntarily. Freedom of choice for consumers and physicians should be preserved.     

Characterizing the Processes for Navigating Internet Health Information Using Real-Time Observations: A Mixed-Methods Approach

BackgroundLittle is known about the processes people use to find health-related information on the Internet or the individual characteristics that shape selection of information-seeking approaches.ObjectiveOur aim was to describe the processes by which users navigate the Internet for information about a hypothetical acute illness and to identify individual characteristics predictive of their information-seeking strategies.MethodsStudy participants were recruited from public settings and agencies. Interested individuals were screened for eligibility using an online questionnaire. Participants listened to one of two clinical scenarios—consistent with influenza or bacterial meningitis—and then conducted an Internet search. Screen-capture video software captured Internet search mouse clicks and keystrokes. Each step of the search was coded as hypothesis testing (etiology), evidence gathering (symptoms), or action/treatment seeking (behavior). The coded steps were used to form a step-by-step pattern of each participant’s information-seeking process. A total of 78 Internet health information seekers ranging from 21-35 years of age and who experienced barriers to accessing health care services participated.ResultsWe identified 27 unique patterns of information seeking, which were grouped into four overarching classifications based on the number of steps taken during the search, whether a pattern consisted of developing a hypothesis and exploring symptoms before ending the search or searching an action/treatment, and whether a pattern ended with action/treatment seeking. Applying dual-processing theory, we categorized the four overarching pattern classifications as either System 1 (41%, 32/78), unconscious, rapid, automatic, and high capacity processing; or System 2 (59%, 46/78), conscious, slow, and deliberative processing. Using multivariate regression, we found that System 2 processing was associated with higher education and younger age.ConclusionsWe identified and classified two approaches to processing Internet health information. System 2 processing, a methodical approach, most resembles the strategies for information processing that have been found in other studies to be associated with higher-quality decisions. We conclude that the quality of Internet health-information seeking could be improved through consumer education on methodical Internet navigation strategies and the incorporation of decision aids into health information websites.