Développement d’un réseau nosographique collaboratif

ObjectivesThe use of massive amounts of digital data in mental health offers interesting perspectives that could influence the evolution of psychiatric nosography. The characteristics of this data could become key elements to understand the future organization of knowledge — and debates — in psychiatry. Such an evolution could take different shapes, including the development of a collaborative and networked psychiatric classification.Materials and methodsSeveral issues related to the use of large amounts of data in psychiatry were identified and developed in this context: (1) the growth of new health related data producers and storers, which could influence the development of some research topics or diagnostics to the detriment of others, depending on the availability or profitability of this data; (2) the fact that mental health data is often available in an unstructured form: textual data, like reports of complementary examinations, reports of hospitalization or expertises, but also imageries or videos, from institutional or alternative sources; (3) the need of scalability and flexibility of this data, to make it possible to integrate recent discoveries as well as to take into account the phenomenon of pathomorphosis or cultural factors in psychiatry. A collaborative framework is proposed to answer each of these issues, including the possibility of integration of different data forms, associated with a complete traceability of sources and a nominal registration. The need to structure data is also specified, with the use of tags to modelize diagnostic consensus that include professionals, patients and families. This collaborative tool would make it possible to consider data resulting from perceptions of patients or their families, enabling patients to benefit from a higher level of confidence and engagement, and limiting the deleterious effects of stigmatization.ResultsThe possibilities of a collaborative web tool integrated into the French Shared Medical File (Dossier Medical Partagé) are described, and two examples of practical situations are presented: A mental health professional reporting his influences on the diagnosis of schizophrenia: he integrates the symptoms described by the German psychiatrist Karl Leonhard (Leonhard classification), cultural references (cinematographic reference like A beautiful mind directed by Ron Howard), and links to articles on medical and psychiatric comorbidities among adults with schizophrenia. In the other example, a psychiatrist uses this tool to develop a collaborative diagnosis that integrated an active participation of the patient around the diagnostic. In France, the latest version of the digital Shared Medical File was launched in November 2018. The integration of a collaborative nosographic tool into this file would be an interesting answer to the difficulties that might happen for its use with patients suffering from mental disorders. It could thus limit the stigmatization of a shared diagnosis and enable a better understanding of practices among mental health professionals.ConclusionThe psychiatrists use specific knowledge resulting from multiple influences and theoretical orientations. The risk of incomprehension of practices in psychiatry by patients and their families being major, nosographic research trying to include the coexistence of these orientations appears necessary. Moreover, in the context of the development of large-scale data processing, it is essential that a collaborative human-scale interpretation of this knowledge exists. This would make the psychiatric nosography an ethical tool, allowing an active participation and dialogue between patients, families and health professionals, that could become key features of future psychiatric nosography.     

Reducing the probability of falsely elevated HbA1c results in diabetic patients by applying automated and educative HbA1c re-testing intervals

IntroductionToo frequent HbA1c measurements may lead to unnecessary treatment modifications of diabetic patients. The aim of this study was to estimate the percentage of falsely elevated HbA1c results in two hospitals, Landeskrankenhaus/Uniklinikum Salzburg (LKH) and Landesklinik St. Veit (STV), as well as to retrospectively investigate the effect of an automated and an educative 60-day re-testing interval (RTI).MethodsThe amount of estimated falsely elevated results (eFER), based on odds calculated using the baseline and the follow-up values and the time between these measurements, the number of HbA1c re-testings within 60 days as well as the overall number of ordered and performed HbA1c analyses were calculated. In LKH, an automated algorithm cancelling inappropriate HbA1c testing was applied, and in STV, educational actions were taken.ResultsBefore RTI-implementation, eFER were 0.9% and 2.1% and within-60-days-re-testing were 15.0% and 7.4% of cases in LKH and STV, respectively. After RTI-implementation, these numbers decreased to 0.2% (p < .001) and 1.8% (p = .869) and within-60-days-re-testing decreased to 1.1% (p < .001) and 3.6% (p = .003) in LKH and STV, respectively. Median monthly HbA1c measurements decreased by 15.8% (p < .001) and 21.1% (p = .002) in LKH and STV, respectively.ConclusionBoth the educational and the automated 60-day-RTI were proven to be efficient in reducing overall HbA1c measurements, re-testing within 60 days and eFER.     

Reimbursement for therapeutic apheresis devices and procedures for using the healthcare insurance system in Japan

The aim of this paper was to explain the insurance coverage status of therapeutic apheresis (excluding CHDF) in Japan, alongside the social system of medical reimbursement and concerns regarding the future sustainability of the healthcare system. Insurance schemes and premiums differed for individuals at different levels in the society (eg, municipal residents, employees, and public servants). Insurance premiums and their rates varied depending on the total household income, the number of people living together, age, and the place of residence. In addition, the medical expense subsidies for children through public expenditure were also described. Japan's generous insurance system and multiple medical expense subsidies provide financial support for patients. With Japan's history of medical expense subsidies based on the policy of supporting intractable diseases, we have established an environment where all citizens can receive therapeutic apheresis when needed if they are affected by a disease for which insurance coverage is indicated.     

全科医师人文素质教育现状的探讨及反思

全科医师立足于基层医疗，旨在提高、满足基层居民卫生服务的全面需求。正是由于全科医师的定位及服务人群的特殊性，相对于专科医师来说，人文素质教育在全科医师培养中占据着更为重要的地位。如今，国内外越来越重视全科医师的人文素质培养，但我国相对于发达国家仍有不足。本文进一步强调了全科医师培养中人文素质教育的重要性，同时通过对比国内外全科医师人文素质教育的现状，进一步反思我国人文素质教育的改进方法。     

WHO药品预认证微生物实验室质量管理的要求与思考

目的:介绍世界卫生组织(WHO)对药品微生物检测实验室的预认证要求,推动我国药品检测质量管理体系的完善和发展。方法:从预认证实验室应遵循的质量管理原则出发,对照我国实验室ISO/IEC 17025体系要求,分析药品微生物检测实验室在质量管理中的不足。结果:预认证实验室更多地采纳了《药品生产质量管理规范》(GMP)的质量管理理念,而我国药品微生物检测实验室在记录与数据可靠性、基于风险的变更控制和偏差调查等方面的应用与实施还存在较大差距。结论:我国药品微生物检测实验室应学习和借鉴国内外GMP的质量管理经验,不断更新理念,改进质量管理体系,更多地以风险评估方式保障检测数据的可靠性。     

再论如何减少产科医疗错误

去年我写了一篇“如何防范和减少产科医疗错误”的文章［1］，刊登在《中国实用妇科与产科杂志》2018年第1期上，编辑部同志告诉我读者对该文的反映还不错，鼓励我再写一篇有关减少产科医疗错误的文章。我想，再写的话，不免有“老调子重弹”之嫌，但编辑部的盛情难却，祇有从命，不当之处，还请读者见谅。     

Changes in the National Endovascular Management of Femoropopliteal Arterial Disease: An Analysis of the 2011–2019 Medicare Data

PurposeTo describe national trends in the utilization of endovascular approaches (including balloon angioplasty, atherectomy, and stent placement) for the management of femoropopliteal peripheral arterial disease (PAD).Materials and MethodsThe Medicare Physician/Supplier Procedure Summary dataset containing 100% of Part B claims was interrogated for years 2011–2019. The Current Procedural Terminology codes specific for femoropopliteal angioplasty, stent placement, and atherectomy were used to create summary statistics for utilization by year, place of service (hospital inpatient, hospital outpatient, and office-based laboratory), and provider specialty (cardiology, radiology, and surgery).ResultsThe use of atherectomy increased from 34,732 (33%) procedures in 2011 to 75,435 (53%) procedures in 2019, and atherectomy became the dominant treatment strategy for femoropopliteal PAD. The relative utilization of stent placement (36,793 [35%] to 28,899 [20%]) and angioplasty only (34,398 [32%] to 38,228 [27%]) decreased concomitantly from 2011 to 2019. By 2019, the use of atherectomy was twofold higher in office-based laboratories than in the outpatient hospital setting (44,767 and 20,901, respectively). Treatment strategy varied by provider specialty in 2011 when cardiologists used atherectomy most frequently (17,925 [43%]), whereas radiologists used angioplasty alone (5,928 [6%]) and surgeons stented (18,009 [37%]) most frequently. By 2019, all specialties utilized atherectomy most frequently (29,564 [59%] for cardiology, 10,912 [58%] radiology, and 33,649 [47%] surgery).ConclusionsThe national approach to endovascular management of femoropopliteal PAD has changed since 2011 toward an implant-free strategy, including a multifold increase in the use of atherectomy. Discordant rates of atherectomy use between the ambulatory hospital and office-based settings highlight the need for comparative effectiveness studies to guide management.     

Emerging Infections Program—State Health Department Perspective

The Emerging Infections Program (EIP) is a collaboration between the Centers for Disease Control and Prevention and 10 state health departments working with academic partners to conduct active population-based surveillance and special studies for several emerging infectious disease issues determined to need special attention. The Centers for Disease Control and Prevention funds the 10 EIP sites through cooperative agreements. Our objective was to highlight 1) what being an EIP site has meant for participating health departments and associated academic centers, including accomplishments and challenges, and 2) the synergy between the state and federal levels that has resulted from the collaborative relationship. Sharing these experiences should provide constructive insight to other public health programs and other countries contemplating a collaborative federal–local approach to collective public health challenges.