Survey of controversial issues of end-of-life treatment decisions in Korea: similarities and discrepancies between healthcare professionals and the general public

Introduction

End-of-life (EOL) treatment issues have recently gained societal attention after the Korean Supreme Court’s ruling that the presumed wishes of an elderly woman in a persistent vegetative state (PVS) should be honored. We tried to evaluate what Koreans thought about controversial issues regarding EOL treatments.

Methods

We surveyed Koreans with the following questions: 1) are ventilator-dependent PVS patients candidates for end-of life treatment decisions? 2) Is withholding and withdrawing EOL treatment the same thing? 3) In an unconscious, terminally ill patient, whose wishes are unknown, how should EOL decisions be made? 4) How should we settle disagreement amongst medical staff and the patient’s family on EOL decisions?

Results

One thousand Koreans not working in healthcare and five hundred healthcare professionals responded to the survey. Fifty-seven percent of Koreans not working in healthcare and sixty seven percent of Korean healthcare professionals agreed that ventilator-dependent PVS patients are candidates for EOL treatment decisions. One quarter of all respondents regarded withholding and withdrawing EOL treatment as equal. Over 50% thought that EOL treatment decisions should be made through discussions between the physician and the patient’s family. For conflict resolution, 75% of Koreans not working in healthcare preferred direct settlement between the medical staff and the patient’s family while 55% of healthcare professionals preferred the hospital ethics committee.

Conclusions

Unsettled issues in Korea regarding EOL treatment decision include whether to include ventilator-dependent PVS patients as candidates of EOL treatment decision and how to sort out disagreements regarding EOL treatment decisions. Koreans viewed withholding and withdrawing EOL treatment issues differently.     

Understanding the demographic characteristics and health of medically uninsured patients

Objective

To determine demographic and diagnostic information about the medically uninsured patient population and compare it with that of the medically insured patient population at a primary care centre.

Design

Medical chart audit.

Setting

Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont.

Participants

Medically uninsured patients who were treated in the Department of Family and Community Medicine at St Michael’s Hospital from 2005 to 2009, as well as randomly selected patients who were insured through the Ontario Health Insurance Program.

Main outcome measures

The following information was obtained from patients’ medical charts: patient’s age, sex, and household income; if the patient had a specific diagnosis (ie, hypertension, type 2 diabetes mellitus, HIV, tuberculosis, substance addiction, or mental health disorder); if the patient accessed a specific category of primary care (ie, prenatal care or routine pediatric care); and the reason for the patient’s uninsured status.

Results

There was no significant difference in the mean age and sex distribution of insured and uninsured patients. The uninsured group had a significantly lower mean household income (P = .02). With the exception of HIV, there was no significant difference in the prevalence of the specific diagnoses studied or in the prevalence of accessing specific categories of primary care between insured and uninsured patients (P > .05). The prevalence of HIV was significantly greater in the uninsured group (24%) than in the insured group (4%) (P = .004). The largest proportion of uninsured patients lacked health insurance owing to the landed immigrant health insurance waiting period (27%), followed by individuals without permanent resident status in Canada (22%). A subgroup analysis of the uninsured, HIV-positive population revealed that the largest proportion of individuals (36%) lacked health insurance because they had no permanent resident status in Canada.

Conclusion

Uninsured and insured patients at the primary care centre did not differ significantly with respect to age and sex distribution; prevalence of hypertension, type 2 diabetes mellitus, tuberculosis, substance addiction, or mental health disorder; or the proportion who sought prenatal or routine pediatric care. The landed immigrant 3-month waiting period was the most common reason that uninsured patients lacked health insurance. Uninsured patients in this study lived in lower-income areas than insured patients did. This, combined with the increased prevalence of HIV in the uninsured group, might lead to a large number of uninsured, HIV-positive patients delaying seeking treatment and might have negative implications for public health.     

Remediation plans in family medicine residency

Objective

To assess use of the remediation instrument that has been implemented in training sites at the University of Montreal in Quebec to support faculty in diagnosing and remediating resident academic difficulties, to examine whether and how this particular remediation instrument improves the remediation process, and to determine its effects on the residents’ subsequent rotation assessments.

Design

A multimethods approach in which data were collected from different sources: remediation plans developed by faculty, program statistics for the corresponding academic years, and students’ academic records and rotation assessment results.

Setting

Family medicine residency program at the University of Montreal.

Participants

Family medicine residents in academic difficulty.

Main outcome measures

Assessment of the content, process, and quality of remediation plans, and students’ academic and rotation assessment results (successful, below expectations, or failure) both before and after the remediation period.

Results

The framework that was developed for assessing remediation plans was used to analyze 23 plans produced by 10 teaching sites for 21 residents. All plans documented cognitive problems and implemented numerous remediation measures. Although only 48% of the plans were of good quality, implementation of a remediation plan was positively associated with the resident’s success in rotations following the remediation period.

Conclusion

The use of remediation plans is well embedded in training sites at the University of Montreal. The residents’ difficulties were mainly cognitive in nature, but this generally related to deficits in clinical reasoning rather than knowledge gaps. The reflection and analysis required to produce a remediation plan helps to correct many academic difficulties and normalize the academic career of most residents in difficulty. Further effort is still needed to improve the quality of plans and to support teachers.     

Tobacco use disorder treatment in primary care: Implementing a clinical system pathway in Alberta

Objective

To test a team-based, site-specific, multicomponent clinical system pathway designed for enhancing tobacco use disorder treatment by primary care physicians.

Design

A prospective cohort study.

Setting

Sixty primary care sites in Alberta.

Participants

A convenience sample of 198 primary care physicians from the population of 2857.

Main outcome measures

Data collection occurred between September 2010 and February 2012 on 3 distinct measures. Twenty-four weeks after the intervention, audits of the primary care practices assessed the adoption and sustainability of 10 tobacco clinical system pathway components, a survey measured changes in physicians’ treatment intentions, and patient chart reviews examined changes in physicians’ consistency with the treatment algorithm.

Results

The completion rate by physicians was 89.4%. An intention-to-treat approach was undertaken for statistical analysis. Intervention uptake was demonstrated by positive changes at 4 weeks in how many of the 10 clinical system measures were performed (mean [SD] = 4.22 [1.60] vs 8.57 [1.46]; P < .001). Physicians demonstrated significant favourable changes in 9 of the 12 measures of treatment intention (P < .05). The 18 282 chart reviews documented significant increases in 6 of the 8 algorithm components.

Conclusion

Our findings suggest that the provision of a tobacco clinical system pathway that incorporates other members of the health care team and builds on existing office infrastructures will support positive and sustainable changes in tobacco use disorder treatment by physicians in primary care. This study reaffirms the substantive and important role of supporting how treatment is delivered in physicians’ practices.     

Development of clinical decision rules to predict recurrent shock in dengue

Introduction

Mortality from dengue infection is mostly due to shock. Among dengue patients with shock, approximately 30% have recurrent shock that requires a treatment change. Here, we report development of a clinical rule for use during a patient’s first shock episode to predict a recurrent shock episode.

Methods

The study was conducted in Center for Preventive Medicine in Vinh Long province and the Children’s Hospital No. 2 in Ho Chi Minh City, Vietnam. We included 444 dengue patients with shock, 126 of whom had recurrent shock (28%). Univariate and multivariate analyses and a preprocessing method were used to evaluate and select 14 clinical and laboratory signs recorded at shock onset. Five variables (admission day, purpura/ecchymosis, ascites/pleural effusion, blood platelet count and pulse pressure) were finally trained and validated by a 10-fold validation strategy with 10 times of repetition, using a logistic regression model.

Results

The results showed that shorter admission day (fewer days prior to admission), purpura/ecchymosis, ascites/pleural effusion, low platelet count and narrow pulse pressure were independently associated with recurrent shock. Our logistic prediction model was capable of predicting recurrent shock when compared to the null method (P < 0.05) and was not outperformed by other prediction models. Our final scoring rule provided relatively good accuracy (AUC, 0.73; sensitivity and specificity, 68%). Score points derived from the logistic prediction model revealed identical accuracy with AUCs at 0.73. Using a cutoff value greater than −154.5, our simple scoring rule showed a sensitivity of 68.3% and a specificity of 68.2%.

Conclusions

Our simple clinical rule is not to replace clinical judgment, but to help clinicians predict recurrent shock during a patient’s first dengue shock episode.     

Evaluation of the Pressure Ulcer Prevention Clinical Decision Report for Bedside Nurses in Acute Care Hospitals

Background

Hospital stays for patients with pressure ulcers (PU) increased nearly 80% from 1992 to 2006. Most PU’s developed during an admission, often despite preventive efforts from clinical staff. Data from Electronic medical records (EMR’s) were used to prepare daily patient risk factor and PU information for nurses to help prevent PU development and exacerbations.

Objectives

The objectives of this study were to determine whether: 1) dissemination of an automated daily report with patient risk and current status of pressure ulcers (“PU Daily”) helps prevent the development of pressure ulcers, and 2) using the PU Daily information impacts the severity of pressure ulcers that develop in an acute care setting.

Methods

A pre-post study with four control units was designed to determine the impact of the PU Daily in intensive care units (ICU) in a large medical center. The control units included ICU’s using the same EMR and similar complexity of cases with a high risk of developing a PU. The pre-post study took place over a six month period (March – August 2009).

Results

A total of 6,735 cases were included in the study. The intervention unit showed a significant decrease (p = 0.004) in PU’s at post-evaluation; none of the four comparison units showed a decrease at the p<0.05 level. The intervention led to a significant reduction in the total number of PU’s documented (p <0.000) and the number of Stage II PU’s (p = 0.046).

Conclusion

The intervention with the PU Daily showed a significant decrease in the total PU’s and severity of PU’s and allowed for implementation of interventions that help prevent the development of PU’s. As EMR’s become more widely available, this intervention showed a reduction in PU’s. Future studies should further develop this intervention and include multiple institutions and patient populations.     

THE ROLE OF REHABILITATION FOLLOWING AUTOLOGOUS CHONDROCYTE IMPLANTATION: A RETROSPECTIVE CHART REVIEW

Purpose/Background:

Clinical outcomes following autologous chondrocyte implantation (ACI) are influenced by multiple factors, including patient demographics, lesion characteristics, quality of the surgical repair, and post‐operative rehabilitation. However, it is currently unknown what specific characteristics of rehabilitation have the greatest influence on clinical outcomes following ACI. The purpose of this study was to conduct a retrospective chart review of patients undergoing ACI with the intent to describe this patient population’s demographics, clinical outcomes, and rehabilitation practices. This study aimed to assess the consistency of the documentation process relative to post‐operative rehabilitation in order to provide information and guide initiatives for improving the quality of rehabilitation practices following ACI.

Methods:

The medical records of patients treated for chondral defect(s) of the knee who subsequently underwent the ACI procedure were retrospectively reviewed. A systematic review of medical, surgical, and rehabilitation records was performed. In addition, patient‐reported outcome measures (IKDC, WOMAC, Lysholm, SF‐36) recorded pre‐operatively, and 3, 6, and 12 months post‐operatively were extracted from an existing database.

Results:

20 medical charts (35.9 ± 6.8 years; 9 male, 11 female) were systematically reviewed. The average IKDC, WOMAC, Lysholm, and SF‐36 scores all improved from baseline to 3, 6 and 12 months post‐operatively, with the greatest changes occurring at 6 and 12 months. There was inconsistent documentation relative to post‐operative rehabilitation, including CPM use, weight‐bearing progression, home‐exercise compliance, and strength progressions.

Conclusions:

Due to variations in the documentation process, the authors were unable to determine what specific components of rehabilitation influence the recovery process. In order to further understand how rehabilitation practices influence outcomes following ACI, specific components of the rehabilitation process must be consistently and systematically documented over time.

Level of Evidence:

2C     

Diagnoses of anxiety and depression in clinical-scenario patients: Survey of Saskatchewan family physicians

Objective

To investigate family physicians’ differential diagnoses of clinical-scenario patients presenting with symptoms of either generalized anxiety disorder (GAD) or a major depressive episode (MDE).

Design

Cross-sectional survey.

Setting

Saskatchewan.

Participants

A total of 331 family physicians practising in Saskatchewan as of December 2007.

Main outcome measures

Type and number of physicians’ differential diagnoses for a GAD-scenario patient and an MDE-scenario patient.

Results

The survey response rate was 49.7% (331 of 666 surveys returned). Most physicians suggested a diagnosis of anxiety (82.5%) for the GAD-scenario patient and a diagnosis of depression (84.2%) for the MDE-scenario patient. In descending order, the 5 most frequent differential diagnoses for the GAD-scenario patient were anxiety, hyperthyroidism, depression, panic disorder or attack, and bipolar disorder. The 5 most frequent differential diagnoses for the MDE-scenario patient were depression, anxiety, hypothyroidism, irritable bowel syndrome, and anemia. Neither a diagnosis of anxiety nor a diagnosis of depression was associated with physicians’ personal attributes (sex, age, and years in practice) or organizational setting (number of total patient visits per week, private office or clinic, solo practice, Internet access, and rural practice setting). However, physicians in solo practice suggested fewer differential diagnoses for the GAD-scenario patient than those in group practice; physicians in practice 30 years or longer suggested fewer differential diagnoses for the MDE-scenario patient than those in practice fewer than 10 years. On average, physicians suggested 3 differential diagnoses for each of the scenarios.

Conclusion

Most family physicians recognize depression and anxiety in patients presenting with symptoms of these disorders and consider an average of 3 differential diagnoses in each of these cases.     

Physician-related barriers to communication and patient- and family-centred decision-making towards the end of life in intensive care: a systematic review

Introduction

Although many terminally ill people are admitted to an intensive care unit (ICU) at the end of life, their care is often inadequate because of poor communication by physicians and lack of patient- and family-centred care. The aim of this systematic literature review was to describe physician-related barriers to adequate communication within the team and with patients and families, as well as barriers to patient- and family-centred decision-making, towards the end of life in the ICU. We base our discussion and evaluation on the quality indicators for end-of-life care in the ICU developed by the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup.

Method

Four electronic databases (MEDLINE, Embase, CINAHL and PsycINFO) were searched, using controlled vocabulary and free text words, for potentially relevant records published between 2003 and 2013 in English or Dutch. Studies were included if the authors reported on physician-related and physician-reported barriers to adequate communication and decision-making. Barriers were categorized as being related to physicians’ knowledge, physicians’ attitudes or physicians’ practice. Study quality was assessed using design-specific tools. Evidence for barriers was graded according to the quantity and quality of studies in which the barriers were reported.

Results

Of 2,191 potentially relevant records, 36 studies were withheld for data synthesis. We determined 90 barriers, of which 46 were related to physicians’ attitudes, 24 to physicians’ knowledge and 20 to physicians’ practice. Stronger evidence was found for physicians’ lack of communication training and skills, their attitudes towards death in the ICU, their focus on clinical parameters and their lack of confidence in their own judgment of their patient’s true condition.

Conclusions

We conclude that many physician-related barriers hinder adequate communication and shared decision-making in ICUs. Better physician education and palliative care guidelines are needed to enhance knowledge, attitudes and practice regarding end-of-life care. Patient-, family- and health care system–related barriers need to be examined.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0604-z) contains supplementary material, which is available to authorized users.     

Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male

Objective and importance

Rapidly progressing degeneration of the hip joint is an uncommon condition presenting to physical therapy. Differential diagnosis can often be difficult, as clinical and radiographic findings do not always coincide leaving clinicians with difficult decision making regarding course of treatment. The purpose of this case report was to describe the differential diagnosis and early management of a patient with rapidly progressing hip pain.

Clinical presentation

A 59-year-old male with a complicated medical history was referred with a diagnosis of severe bilateral hip osteoarthritis. Clinical presentation of insidious onset, severe bilateral groin and anterior thigh pain with rapid progression of functional decline lead to the differential diagnosis of bilateral avascular necrosis.

Intervention

The patient received seven manual physical therapy sessions over the course of one month.

Conclusion

During this time, the patient’s Lower Extremity Functional Scale score worsened from 33 to 21. The persistence of the patient’s painful symptoms and continued functional decline helped determine cessation of manual therapy and referral back to his GP for further diagnostic testing and eventual correct diagnosis. This case highlights the importance of monitoring patient prognosis using outcome measures leading to a change in patient management strategies.     

Clinical Summarization Capabilities of Commercially-available and Internally-developed Electronic Health Records

Objective

Clinical summarization, the process by which relevant patient information is electronically summarized and presented at the point of care, is of increasing importance given the increasing volume of clinical data in electronic health record systems (EHRs). There is a paucity of research on electronic clinical summarization, including the capabilities of currently available EHR systems.

Methods

We compared different aspects of general clinical summary screens used in twelve different EHR systems using a previously described conceptual model: AORTIS (Aggregation, Organization, Reduction, Interpretation and Synthesis).

Results

We found a wide variation in the EHRs’ summarization capabilities: all systems were capable of simple aggregation and organization of limited clinical content, but only one demonstrated an ability to synthesize information from the data.

Conclusion

Improvement of the clinical summary screen functionality for currently available EHRs is necessary. Further research should identify strategies and methods for creating easy to use, well-designed clinical summary screens that aggregate, organize and reduce all pertinent patient information as well as provide clinical interpretations and synthesis as required.     

Family practice versus specialist care for low-risk obstetrics: Examining patient satisfaction in Newfoundland and Labrador

Objective

To investigate patient satisfaction with 3 models of low-risk obstetrics care: solo care by a GP, group care by GPs, and specialist care.

Design

Three-arm study comparing results of a self-administered, anonymous questionnaire.

Setting

Two academic family practices and the labour and delivery ward in St John’s, Nfld.

Participants

A total of 220 women deemed to have low-risk pregnancies; 82 women completed the questionnaire (37% response rate).

Main outcome measures

Patient satisfaction scores obtained from a modified version of the Patient Expectations and Satisfaction with Prenatal Care instrument.

Results

Low-risk maternity patients’ satisfaction with obstetric care provided by GPs in a group-care setting was equivalent to that with obstetric care provided by GPs working solo and greater than that with obstetric care provided by specialists.

Conclusion

Patients found that group care by GPs was an acceptable means of receiving obstetric services in a low-risk setting. Therefore, a group practice model might provide an attractive means for FPs to keep obstetrics within the scope of primary care.     

Roles of nurse practitioners and family physicians in community health centres

Objective

To describe the models of practice used by nurse practitioners (NPs) and FPs in community health centres (CHCs), and to examine the roles of NPs and FPs in these models.

Design

Cross-sectional study using an organizational survey completed by managers of the CHC sites, as well as administrative data on patient sociodemographic characteristics and encounter activities.

Setting

A total of 21 CHCs (13 main sites and 8 satellite sites) operating in eastern Ontario during the period from December 1, 2006, to November 30, 2008.

Participants

A total of 44 849 patients, 53 full-time equivalent FPs, and 41 full-time equivalent NPs.

Main outcome measures

Family physicians’ and NPs’ models of practice, the sociodemographic characteristics and medical profiles of patients who were treated in each model of practice, and FPs’ and NPs’ use of time.

Results

Patients were attributed to 1 of 3 models of practice in CHCs based on the proportion of visits to FPs and NPs: FP care (53% of patients), NP care (29%), and shared care (18%). Patients who received care in the NP model of practice were younger and more likely to be female, be homeless, and not have postsecondary education. Patients who received care in the FP model of practice had more complex medical conditions (cardiovascular disease, mental illness, lung disease, and diabetes) and more annual visits. Patients who received care in the shared care model had intermediate profiles. Nurse practitioners performed more off-site care and walk-in visits. Family physicians and NPs spent a similar proportion of time performing various duties such as direct clinical care and administration tasks.

Conclusion

Although NPs mainly cared for their own patient panels (in the NP care model), they did share some patients with FPs and provide some care to patients under the FP model of practice. Patients who were cared for by FPs and NPs had quite different characteristics.     

PREVALENCE OF MUSCULOSKELETAL PAIN AMONG SWIMMERS IN AN ELITE NATIONAL TOURNAMENT

Background

Professional swimmers are often affected by a high number of injuries due to their large amount of training. The occurrence of musculoskeletal pain during an important tournament has not been investigated.

Objective

The objective of the study was to assess the prevalence of musculoskeletal pain and its characteristics in professional swimmers. Secondary objectives included evaluating the swimmers’ injury history over the previous 12 months, and examining the association of the presence of pain with personal and training characteristics of the swimmers.

Design

Observational, cross‐sectional study

Method

Two‐hundred and fifty‐seven swimmers who participated in the Brazilian Swimming Championship were included in the study and answered a questionnaire about personal and training characteristics, presence of pain, and injuries in the previous 12 months. The relative risk of presence of pain was calculated for the following variables: gender, BMI, stroke specialty, swimmer''s position, strength training, practice of another physical activity, and previous injuries.

Results

The prevalence of musculoskeletal pain was about 20%, with 60% of swimmers reporting at least one injury in the previous 12 months. The shoulder was the most commonly affected region and tendinopathy was the most common type of previous injury. No significant relationships were found between the presence of pain and personal or training characteristics.

Conclusions

The results demonstrated that the prevalence of musculoskeletal pain in professional swimmers participating in the most important Brazilian national tournament was approximately 20%, while the majority of participants reported previous injuries in many areas.

Level of Evidence

2c     

RELIABILITY OF VIDEO‐BASED QUANTIFICATION OF THE KNEE‐ AND HIP ANGLE AT FOOT STRIKE DURING RUNNING

Introduction:

In clinical practice, joint kinematics during running are primarily quantified by two‐dimensional (2D) video recordings and motion‐analysis software. The applicability of this approach depends on the clinicians’ ability to quantify kinematics in a reliable manner. The reliability of quantifying knee‐ and hip angles at foot strike is uninvestigated.

Objective:

To investigate the intra‐ and inter‐rater reliability within and between days of clinicians’ ability to quantify the knee‐ and hip angles at foot strike during running.

Methods:

Eighteen recreational runners were recorded twice using a clinical 2D video setup during treadmill running. Two blinded raters quantified joint angles on each video twice with freeware motion analysis software (Kinovea 0.8.15)

Results:

The range from the lower prediction limit to the upper prediction limit of the 95% prediction interval varied three to eight degrees (within day) and nine to 14 degrees (between day) for the knee angles. Similarly, the hip angles varied three to seven degrees (within day) and nine to 11 degrees (between day).

Conclusion:

The intra‐ and inter rater reliability of within and between day quantifications of the knee‐ and hip angle based on a clinical 2D video setup is sufficient to encourage clinicians to keep using 2D motion analysis techniques in clinical practice to quantify the knee‐ and hip angles in healthy runners. However, the interpretation should include critical evaluation of the physical set‐up of the 2D motion analysis system prior to the recordings and conclusions should take measurement variations (3‐8 degrees and 9‐14 degrees for within and between day, respectively) into account.

Level of evidence:

3