Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study

BACKGROUND: Many patients with asthma or chronic obstructive pulmonary diseaseuse their medication inhalers incorrectly. General practitioners,pharmacists and other health care providers do not always havethe opportunity to instruct patients in correct inhaler technique. OBJECTIVE: To find out whether the inhaler technique and respiratory symptomsof patients can be improved after instruction by practice assistants. METHODS: Single blind, randomized intervention study in which 48 patientswho had been using a dry powder inhaler for at least one monthtook part. Their inhaler technique was videotaped on two visitswith a two-week interval between visits. The inhaler techniqueon the videos was subsequently scored by two experts on ninecriteria. At both visits the patients completed a questionnaireabout their respiratory symptoms. After the first video, 25patients were randomly chosen to receive instruction from oneof six practice assistants who had followed a one evening courseabout inhaler instruction, and who had been issued an instruction-set. RESULTS: The patients who received instruction had a significantly greaterreduction in number of mistakes at the second visit than thepatients who did not (P = 0.01). The instructed patients alsoreported less dyspnoea at the second visit (P = 0.03). No effectof instruction was found on wheezing, cough and sputum production. CONCLUSION: The inhaler technique of patients can be improved significantlyby the instruction of patients by trained practice assistants,possibly resulting in less dyspnoea. Keywords. Administration-inhalation, obstructive lung diseases, airways symptoms, patient-education, general practice.     

The role of cognitive impairment in the use of the Diskus inhaler

Background and PurposeDrugs delivered by metered-dose inhalers and dry powder inhalers (DPIs) are a mainstay in the treatment of chronic lung disease; however, previous studies suggest cognitive impairment hinders proper use of inhalers. The purpose of this study was to determine the relationship between the score on the Mini-Mental State Exam (MMSE) and the ability of nursing facility residents to complete the steps required for proper use of a multiunit-dose DPI (Diskus).MethodsNursing facility residents who had never used a multiunit-dose DPI (Diskus), who scored between 10 and 24 inclusive on the MMSE, and who were able to hold a breath for 10 seconds were recruited for an observational study to test their ability to use a placebo-loaded Diskus when supervised and assisted by personnel trained in the proper use the Diskus. Ability to use the DPI was assessed by the Diskus Evaluation Rating Scale (DERS), an instrument developed specifically for this study. Possible scores on the DERS ranged from 0 to 19, with a score of 0 indicating no limitations in any of the steps involved in using the Diskus and 19 indicating inability to do any of the steps after 3 supervised attempts.ResultsForty Diskus-naïve nursing facility residents (86 ± 9 years of age; 32 women) with MMSE scores between 10 and 24 inclusive and the ability to hold a breath for 10 seconds were enrolled in the study. Mean MMSE scores were 17.4 ± 4.2, whereas the mean score on the DERS was 5.1 ± 3.2 (range 1–16). After controlling for age, gender, and education, a significant inverse relationship was noted between scores on the MMSE and the DERS such that for every 1-point increase on the MMSE, the subject's DERS score decreased by 0.345 points (P = .003). Overall, 38 of the 40 subjects with MMSE scores between 10 and 24 inclusive were able to use the Diskus successfully.ConclusionFor MMSE scores, the better the performance on the MMSE, the better the performance on the DERS. More important, 95% of the subjects in this study could use the Diskus successfully when properly supervised. In contrast to earlier studies, these findings suggest that a multiunit-dose DPI can be prescribed as one component of the regimen for chronic lung disease in patients with substantial cognitive impairment.     

Work-related post-traumatic stress disorder: report of five cases

Post-traumatic stress disorder (PTSD) may arise after events involving a risk to physical integrity or to life, one’s own or that of others. It is characterized by intrusive symptoms, avoidance behaviors, and hyper-excitability. Outside certain categories (e.g., military and police), the syndrome is rarely described in the occupational setting. We report here five unusual cases of work-related PTSD, diagnosed with an interdisciplinary protocol (occupational health visit, psychiatric interview, psychological counselling and testing): (1) a 51-yr-old woman who had undergone three armed robbery attempts while working in a peripheral post office; (2) a 53-yr-old maintenance workman who had suffered serious burns on the job; (3) a 33-yr-old beauty center receptionist after sexual harassment and stalking by her male employer; (4) a 57-yr-old male psychiatrist assaulted by a psychotic outpatient; (5) a 40-yr-old woman, sales manager in a shoe store, after physical aggression by a thief. All patients required psychiatric help and pharmacological treatment, with difficulty of varying degrees in resuming work. We conclude that PTSD can develop even in professional categories generally considered to be at low risk. In such cases, a correct interdisciplinary diagnostic approach is fundamental for addressing therapy and for medico-legal actions.     

Dosage aerosols; problems with the inhalation technic

The inhalation techniques of 77 patients using a dosing aerosol were videotaped before, immediately after and (in 55 cases) three weeks after they viewed an instruction video tape. The inhalation technique was assessed on 9 points. Before the instruction only 2% had a correct and 49% a completely faulty technique. After instruction, these figures were 65% and 13%, respectively. After three weeks, 12% were found to have regressed to only partially correct use.     

Patient satisfaction with nurse-led telephone follow-up in women with lower urinary tract symptoms

We assessed the clinical effectiveness and patient satisfaction with nurse-led telephone follow-up of women with lower urinary tract symptoms. Participants were offered telephone follow-up with a nurse instead of a conventional outpatient appointment. Suitability was decided by the doctor who saw the women at her last visit. The consultation was conducted using the same principles as a routine clinic visit. Patient satisfaction was evaluated by postal questionnaire and they were also sent a standard urinary continence questionnaire, the Kings Health Questionnaire (KHQ), to evaluate their current symptoms. In total, 116 women were included. The mean number of telephone consultations was 2 (range 1-12). The mean overall satisfaction score was 77 (maximum 100, where a higher score indicates greater satisfaction). Only 16 patients (17%) did not prefer telephone follow-up to a clinic visit. Women who had been discharged via the telephone follow-up clinic expressed similar mean satisfaction scores to those whose next visit was a clinic visit (80 and 82, respectively). The KHQ also indicated that the patients had been appropriately discharged or given a further follow-up appointment. Nurse-led telephone follow-up is associated with high satisfaction and has the advantages of consistent follow-up by the same clinician, convenience to the patient and cost-savings.     

Inhalation techniques in the treatment of asthma

In the pharmacological treatment of asthma, the most suitable way is by inhalation, since this enables us to achieve a greater concentration of medicine in the affected organ than systemic medication, and besides the latter's secondary effects are minimized. The suitable use of inhalers and hence their efficacy depends on very different factors. Some of those of a merely technical kind are as follows: A suitable volume of inhalation. The rhythm of inhalation. The length of the inspiratory apnea following administration of the medicine. The coordination between the inspiration of the aerosol and activation of the device, in the case of the metered dose inhaler (MDI). One of the reasons for the incorrect use of MDI aerosols is the lack of coordination between activation of the device and inspiration. This has led to the design of different devices that avoid the need for this coordination, such as: inhalation chambers and devices for inhaling dry dust. It has also been suggested in the literature that the causes of these mistakes are to be found in the health professionals not knowing, or not suitably teaching the patients how to handle the devices. In spite of being designed to facilitate correct administration, suitable knowledge of the technique of their use by the patient is required.     

无锡市社区老年人群主观认知下降患者门诊就诊率调查及其影响因素分析

目的 了解无锡市社区老年人群主观认知下降（SCD）患者的门诊就诊率及其影响因素,为阿尔茨海默病（AD）超早期精准干预提供参考依据。方法 2021年2—8月,以居民健康档案为线索,采用分层整群随机抽样方法,在无锡市社区招募60岁及以上老年人1 500名,采用一般情况调查表、简易老年人认知筛查问卷（BECSI）、老年快速认知筛查量表（QCSS-E）、成套核心神经心理测验(CNT)及相关实验室检查进行SCD筛查和临床诊断,分析SCD患者的门诊就诊率及影响因素。结果 共获得有效样本1 314名,检出SCD患者379例,占比28.84%,其中因主观认知下降在门诊就诊的仅91例,门诊就诊率为24.01%。多因素logistic回归分析结果显示,经常参加社区老年健康讲座（OR=8.323,95%CI:2.955～23.442）、对痴呆早期预防持积极态度（OR=3.852,95%CI:1.152～12.883）、了解SCD相关知识（OR=2.762,95%CI:1.258～6.061）、病程3年（OR=4.072,95%CI:1.282～12.935）是影响SCD患者就诊的积极因素;而受教育程度为小学...     

Impact of a national medical fee schedule revision on the cessation of physician home visits among older patients in Tokyo: A retrospective study

As Japan's population continues to age rapidly, the national government has implemented several measures to improve the efficiency of healthcare services and to control rising medical expenses for older patients. One such measure was the revision of the medical fee schedule for physician home visits in April 2014, in which eligibility for these visits was restricted to patients who are unable to visit outpatient clinics without assistance. Through an investigation of patients who were receiving physician home visits in Tokyo, this study examines whether this fee schedule revision resulted in an increase in patients who transitioned from home visits to outpatient care. In a retrospective analysis of health insurance claims data, we examined 80,914 Tokyo residents aged 75 years or older who had received at least one physician home visit between January and May 2014. The study period was divided into four periods (January–February, February–March, March–April, and April–May), and we examined the number of patients receiving home visits in the index month of each period who subsequently transitioned to outpatient care in the following month. Potential factors associated with this transition to outpatient care were examined using a generalised estimating equation. The March–April period that included the fee schedule revision was significantly associated with a higher number of patients who transitioned from home visits in the index month to outpatient care in the following month (odds ratio: 4.46, p < 0.001) than the other periods. In addition, patients receiving home visits at residential facilities were more likely to transition to outpatient care (odds ratio: 10.40, p < 0.001). These findings indicate that the fee schedule revision resulted in an increase in patients who ceased physician home visits and began visiting outpatient clinics for treatment.     

Knowledge about genital herpes amongst first time attenders at a department of genitourinary medicine

BACKGROUND AND AIMS: Genital herpes is the most common cause of genital ulceration in the developed world, and its prevalence in the United Kingdom is rising. Public knowledge of the infection is often limited. We aimed to assess knowledge among patients attending an outpatient genitourinary clinic in Scotland. METHODS: A questionnaire was designed to collect information about educational qualifications and knowledge of genital herpes. In the knowledge section, each correct answer was given a score of 1; thus the maximum possible score was 12. Two hundred and ten individuals who attended as new patients at a walk-in genitourinary medicine clinic were invited to complete the questionnaire. RESULTS: Two hundred and seven patients completed the questionnaire. Overall 63% of responses were answered correctly. Knowledge of genital herpes was better in patients who worked in healthcare (8.3 v 6.9, p=0.019) and in patients with educational qualifications gained from college or university compared to those gained at school (7.6 v 6.5, p=0.009). Level of knowledge was not related to age or gender; receiving sex education at school did not appear to improve knowledge of genital herpes. CONCLUSION: Knowledge of genital herpes among patients attending an outpatient genitourinary clinic in Scotland is reasonable but needs to improve to combat the rising prevalence of the infection. The areas of misunderstanding identified in our study could be targeted for public education.     

Variations in clinical decisions: a study of orthopaedic patients.

Three groups of patients were clinically reviewed within a new orthopaedics department: patients who were on an inpatient waiting list for surgery; new referrals from general practitioners; and patients who had been referred earlier and were awaiting an appointment for outpatient consultation. Approximately two-fifths of patients who were already on the inpatient waiting list, and who had confirmed their wish to remain on it, were considered on clinical review not to require inpatient treatment. A third of patients attending for first outpatient consultations were immediately returned to the continuing care of their general practitioner and this proportion was higher (47%) amongst patients who were waiting for outpatient appointments and who had not been referred to a named hospital consultant. These findings draw attention to the possible inappropriate use of specialist hospital facilities because of clinical decisions taken by some general practitioners and also to variations in the threshold for surgical intervention used by hospital consultants. It is important that the medical profession develops a consensus approach to the clinical management of patients with common conditions. It is also important that clinical review of patients on inpatient waiting lists, especially those who have been waiting a long time, becomes a routine part of waiting list management. Under the new British health care system, it is likely that purchasers of health care will seek to ensure that these issues are being dealt with by hospitals with which they are considering placing contracts.     

门诊患儿雾化吸入依从性的研究及护理对策

目的探讨门诊患儿对雾化吸入的依从性,并提出针对性护理措施。方法选择儿科门诊接受雾化吸入治疗的婴幼儿患者162例,随机分为观察组和对照组,观察组83例,对照组79例,对照组给予常规护理,观察组在此基础上采用个性化护理干预,观察两组患儿在雾化吸入治疗过程中的配合接受、拒绝治疗的情况,对两组患儿对雾化吸入的依从性进行比较分析。结果观察组患儿与对照组相比较,对雾化吸入的依从性明显提高,差异有统计学意义（P〈0.05）。结论针对患儿不同年龄段心理发展特点,采取个性化护理干预可以更好的配合治疗,提高患儿对雾化吸入的依从性。     

北京市大气PM2.5污染对某医院儿科门诊量影响的时间序列研究

目的 探讨北京市大气PM2.5对医院儿科门诊量的影响。方法 采用基于泊松回归的广义线性模型(GLM),控制时间的长期趋势、季节趋势、星期几效应、节假日效应、流感、气象因素等混杂因素后,分析2013-2015年北京市大气PM2.5对某医院儿科门诊量的影响。结果 单污染物模型分析显示PM2.5对儿科总门诊量、儿科呼吸系统疾病门诊量和儿科其他疾病门诊量的影响均有统计学意义,且以当天的效应最强,PM2.5浓度每升高10μg/m³,上述门诊量分别增加0.525%(95%CI:0.428%~0.622%)、0.589%(95%CI:0.473%~0.706%)、0.393%(95%CI:0.218%~0.569%)。多污染物模型分析结果显示,引入其他污染物后,PM2.5对儿科总门诊量和呼吸系统疾病门诊量的影响仍有统计学意义,PM2.5浓度每升高10μg/m³,上述门诊量分别增加0.570(0.342~0.797)、0.697(0.421~0.973);PM2.5对儿科其他疾病门诊量的影响无统计学意义。结论 北京市PM2.5浓度升高可能会引起医院儿科呼吸系统疾病门诊量的增加。     

Continuity of primary care: to whom does it matter and when?

BACKGROUND: Inconsistent findings on the value of continuity of care can stem from variability in its importance to different subsets of patients. We therefore examined the association among patient and visit characteristics and extent to which the patient valued continuity of care (PVC). We hypothesized that continuity would be more important to patients who are older, sicker, and female, who have established a relationship with their physician, and whose visit addresses more complex problems. METHODS: A study of 4,454 consecutive outpatient visits to 138 community-based family physicians used a 3-item measure (alpha = 0.67) of PVC. The patient's report of (1) the adequacy of primary care for the visit and (2) satisfaction with the physician on that visit was assessed with multiple measures. Analyses examined the associations among PVC and patient-reported satisfaction with the physician and adequacy of the visit. RESULTS: Extremes of age, female sex, less education, Medicare and Medicaid insurance, number of chronic conditions and medications, number of visits to the practice, and worse self-reported health status were associated with higher value placed on continuity (P < .001 for all except sex, where P = .015). Patients who value continuity and did not see a regular physician rated adequacy of the visit lower (for 7 attributes of the visit) than those seeing their own physician. Satisfaction with the physician for the visit was greatest among patients who value continuity and saw their regular physician. CONCLUSIONS: Continuity of physician care is associated with more positive assessments of the visit and appears to be particularly important for more vulnerable patients. Health care systems and primary care practices should devote additional effort to maintaining a continuity relationship with these vulnerable patients.     

Videoconferencing for orthopaedic outpatients: one-year follow-up

We studied whether consultations via videoconferencing and traditional outpatient clinic visits differ in terms of the implementation of the patient management plan during a one-year follow-up. First-admission and follow-up orthopaedic patients were randomly allocated to an outpatient visit at the surgical department of Oulu University Hospital or to videoconferencing at a health centre in Pyh?j?rvi. In a prospective one-year study, there were 145 consecutive orthopaedic patients who met the inclusion criteria: 84 referred for their first visit to a specialist and 61 of them for follow-up. There were 66 males (46%) in the study population. Over half the patients had some form of regenerative arthritis: 15% had hip arthritis, 33% knee arthritis and 4% other arthritis. There were no differences in the implementation of the management plan between the two groups. The study showed that videoconferencing is a valid alternative to outpatient clinic visits for orthopaedic specialist consultations.     

Assessment of inhalation technique in children with asthma, Abha, Saudi Arabia

The inhalation technique of asthma in children was assessed using the criteria defined by the standardized inhaler checklist of the Netherlands Asthma Foundation and Dutch asthma foundation. Four hundred and thirty seven newly referred patients to chest clinic, department of pediatric, Assir Central Hospital, Southwestern Saudi Arabia were instructed to demonstrate their inhalation technique and to fill out a questionnaire related to the inhalation instructions received before their referral. Results: Four hundred and thirty seven patients newly referred for evaluation of their asthma (5-12 years of age with mean age of 7.16+1.69 years, 202 (46.2%) girls, 235 (53.8%) boys were included in the study. Two hundred two (46.2%) patients use MDI. The remaining (53.8%) patients use the DPI, 123 (52.35%) of them use turbohalers while 112 (47.65%) use diskhalers. Only 36 patients (8.2 %) completed the assessment without making any mistake. Of the remainders, 399 (91.8%) made one or more mistakes. Of the MDI users, eleven patients (5.4%) performed correctly all the steps, and 54 (26.7%) performed correctly four or more steps. Ten (8.9%) of the diskhaler users performed all the steps correctly and forty nine (43.8) performed correctly four or more steps. Fifteen (12 2%) of the turbohaler users performed correctly all the steps and ninety five (77.2%) performed correctly four or more steps. One hundred five of the male patients (44.7%), performed correctly more than three steps as compared to 93 of the female patients (46.5) with p value=0.704. One hundred and one patients (67.3%) between the age of 8-12 years performed more than three steps correctly as compared to 97 (33.8%) of patients aged 5-7 years (p=0.001). Conclusion: In conclusion, many asthmatic children use their inhaler devices too poorly with the result of an unreliable drug delivery. Turbohaler device inhalation technique was the easiest, followed by diskhaler then lastly the MDI. Education of asthmatic children and their families is highly needed to make sure the patient perform the correct inhalation technique.     

Impact of craving on alcohol relapse during, and 12 months following, outpatient treatment

AIMS: This study investigated the relationship between craving in abstinent alcohol-dependent patients measured by the Obsessive Compulsive Craving Scale (OCDS) (Anton et al., 1995) and relapse during and after completion of an intensive outpatient treatment programme. METHODS: In a prospective study, participants were interviewed at entry to, and end of, an outpatient treatment programme, and 12 months after the end of the programme. To measuring craving the OCDS total score by Anton et al. (1995) and the three-factor model by Kranzler et al. (1999) were used. OCDS was administered at the beginning of treatment (when all patients were abstinent), and at the end of treatment in those who were abstinent and had completed the programme. RESULTS: Of 103 alcohol-dependent patients, 74 completed the treatment programme and at follow-up after 12 months 97% of these patients were personally re-interviewed. Thirty-two patients (31%) relapsed during the treatment phase. They had significantly higher craving measured by the total OCDS score and a significantly higher score on the subscales 'obsessions' and 'drinking control and consequences' compared to abstinent patients. Of the 74 patients who completed the programme 16% had a major relapse in the next 12 months. Major relapse was predicted by the total OCDS score and the subscale 'obsessions'. CONCLUSIONS: OCDS total score predicts relapse in outpatient treatment. Treatment and aftercare of patients with high craving should be intensified. In our study design, the subscales of the three-factor model by Kranzler et al. (1999) provided only little information gain compared to the OCDS total score.     

Unscheduled admissions within 84 hours of an outpatient visit: a measure of ambulatory care quality?

The occurrence screen, unscheduled medical or surgical admission within 84 hours of an outpatient visit, was found not to be useful in assessing quality of care or in suggesting actions to improve quality. A main finding of this study was the rather high percentage (69%) of episodes in which the reason for unscheduled admission was an exacerbation of a problem that could not be anticipated at the time of the outpatient visit. The quality of care at most institutions is likely to be high enough that alternative approaches to assessing and improving quality are recommended.     

The Effect of Eye Drop Technique Education in Patients With Glaucoma

Education about how to administer eye drops may improve a patient’s ability to instill his or her eye drops correctly. Our objectives were to (a) document the methods providers use to educate glaucoma patients about eye drop technique; (b) determine whether eye drop technique education varies by provider and patient characteristics; and (c) evaluate whether education predicts improved patient technique. We conducted an 8-month longitudinal study of 279 glaucoma patients and 15 providers in which we recorded on videotape the content of glaucoma office visits at two time points (baseline and 4- to 6-week follow-up) and videotaped patient eye drop technique at three time points (baseline, 4- to 6-week follow-up, and 8-month follow-up). Mann–Whitney rank sum tests were used to determine whether education was associated with improved patient eye drop technique over time. Ninety-four patients (34%) received technique education at either visit; 31% received verbal education and 10% received a technique demonstration. Only 24 patients (47%) who were new to eye drops received technique education at the baseline visit. Patients who were new to drops at baseline (p = .008) and patients who asked a question about drops (p < .001) were more likely to receive technique education. Education was not associated with improved technique. Eye drop technique education occurs infrequently during glaucoma office visits. Future studies should compare the effectiveness of different educational methods, such as patient demonstration versus provider verbal instruction, to determine which method is best at improving patient eye drop technique.     

Medication documentation in a primary care network serving North Carolina medicaid patients: results of a cross-sectional chart review

ABSTRACT: BACKGROUND: Medical records that do not accurately reflect the patient's current medication list are an open invitation to errors and may compromise patient safety. METHODS: This cross-sectional study compares primary care provider (PCP) medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the association of congruence with demographic, clinical, and practice characteristics. Medication list congruence was measured as agreement of pharmacy claims with the entire PCP chart, including current medication list, visit notes, and correspondence sections. RESULTS: Congruence between pharmacy claims and the PCP chart was 65%. Congruence was associated with large chronic disease burden, frequent PCP visits, group practice, and patient age [greater than or equal to]45 years. CONCLUSION: Agreement of medication lists between the PCP chart and pharmacy records is low. Medication documentation was more accurate among patients who have more chronic conditions, those who have frequent PCP visits, those whose practice has multiple providers, and those at least 45 years of age. Improved congruence among patients with multiple chronic conditions and in group practices may reflect more frequent visits and reviews by providers.