Encouraging primary care research: evaluation of a one-year,doctoral clinical epidemiology research course

Objective: Research and PhDs are relatively rare in family medicine and primary care. To promote research, regular one-year research courses for primary care professionals with a focus on clinical epidemiology were started. This study explores the academic outcomes of the first four cohorts of research courses and surveys the participants’ perspectives on the research course. Design: An electronic survey was sent to the research course participants. All peer-reviewed scientific papers published by these students were retrieved by literature searches in PubMed. Setting: Primary care in Finland. Subjects: A total of 46 research course participants who had finished the research courses between 2007 and 2012. Results: Of the 46 participants 29 were physicians, eight nurses, three dentists, four physiotherapists, and two nutritionists. By the end of 2014, 28 of the 46 participants (61%) had published 79 papers indexed in PubMed and seven students (15%) had completed a PhD. The participants stated that the course taught them critical thinking, and provided basic research knowledge, inspiration, and fruitful networks for research. Conclusion: A one-year, multi-professional, clinical epidemiology based research course appeared to be successful in encouraging primary care research as measured by research publications and networking. Activating teaching methods, encouraging focus on own research planning, and support from peers and tutors helped the participants to embark on research projects that resulted in PhDs for 15% of the participants.

• Key Points

• Clinical research and PhDs are rare in primary care in Finland, which has consequences for the development of the discipline and for the availability of clinical lecturers at the universities.

• A clinical epidemiology oriented, one-year research course increased the activity in primary care research. Focus on own research planning and learning the challenges of research with peers appeared to enhance the success of a doctoral research course.

• A doctoral research course encouraged networking, and the course collaboration sometimes led to paper co-authoring.

• In the Nordic countries, the primary care health professionals are used to working in multi-professional teams. A multi-professional strategy also seems fruitful in doctoral research education.

     

Interprofessional pharmacotherapy workshop: intervention to improve health professionals’ and students’ attitudes towards collaboration between physicians and pharmacists

ABSTRACT

Collaboration between physicians and pharmacists is recognized as an important factor for reducing medication errors and improving patient outcomes. Therefore, two pharmacotherapy workshops were delivered in Croatia - one for pre-registration medical (n=42, 4th-6th year) and pharmacy (n=38, 4th-5th year) students, and the other one for physicians (n=18) and pharmacists (n=23). The purpose of this study was to determine whether participation in common pharmacotherapy workshop could improve attitudes among participants towards interprofessional collaboration between pharmacists and physicians. Attitudes were measured by validated questionnaire “Scale of Attitudes Towards Collaboration Between Pharmacists and Physicians” at the beginning and at the end of the workshops. Three complex clinical scenarios were presented during the workshops. Participants were given general information about cases (all participants) and 2 groups of specific information (only for medical students/physicians and only for pharmacy students/pharmacists). For the first scenario, medical and pharmacy students/professionals were not allowed to exchange their specific information. However, participants collaborated for the 2nd and 3rd scenarios in order to achieve the hypothesized therapeutic goals. Before the workshops, pharmacists and pharmacy students showed more positive attitudes than physicians and medical students. However, the workshop contributed in closing the gap by equating health care professionals’ attitudes. Additionally, students’ attitudes were more positive after the workshop with an increase of 10% for medical and 2.2% for pharmacy students. This study indicates that interprofessional pharmacotherapy workshops could significantly improve attitudes toward collaboration between physicians and pharmacists for both students and practicing professionals.     

Nasal Polyposis and Its Association with Cardiac Functions

ObjectiveThe aim of the study was to ascertain the effect of nasal polyposis on cardiac functions.Material and MethodsA prospective randomized interventional open-label endpoint-controlled study was conducted in an academic tertiary care hospital. Thirty-one patients with chronic rhinosinusitis with nasal polyposis were enrolled and administered fluticasone furoate nasal spray for 3 weeks before randomly segregation into surgical or medical group. The treatment continued for 3 months in both groups. The SNOT-22 (Sino-Nasal Outcome Test-22) score, polyp grade, and right ventricular and pulmonary arterial functions were recorded in both groups before and after 3 months of the intervention.ResultsBoth groups had significant improvement in SNOT-22 scores after 3 months of intervention. Both groups showed improvement in cardiac functions, but statistical significance was found only in subjects who underwent surgery.ConclusionNasal polyp affects cardiac functions, and this needs further evaluation and research through studies on large samples.     

Psychosocial issues need more attention in COPD self-management education

Abstract

Objective: To find out how regularly the contents of patient education regarded as essential for COPD patients’ self-management are provided by healthcare professionals in specialised healthcare (SHC) and primary healthcare (PHC) in Finland.

Design: A cross-sectional study based on an e-questionnaire with 42 items on the content of self-management education of COPD patients.

Setting: The study sample included all public SHC units with pulmonary outpatient clinics (n?=?29) and nine out of 160 health centres in Finland.

Subjects: 83 doctors and 162 nurses.

Main outcome measures: The respondents’ answers on how regularly they included the contents regarded as essential for COPD patients’ self-management in their education of COPD patients.

Results: COPD patients were educated regularly on medical issues regarding COPD treatment, such as smoking cessation, exercise and pharmacological treatment. However, issues vital for coping with the disease, such as psychological well-being, stress management or fatigue, were often ignored. Patient education in SHC seemed to be more systematic than education in PHC. The education provided by the asthma/COPD nurses (n?=?70) was more systematic than the education provided by the other nurses (n?=?84).

Conclusion: Healthcare professionals’ continuous education should cover not only the medical but also the psychosocial aspects of coping with COPD. The role of doctors and nurses should be considered to ensure that there is no gap in COPD patients’ education. Training asthma/COPD nurses and promoting specialised nurse-led asthma/COPD clinics in primary care could be beneficial while improving practices of patient education that enhance patients’ ability to cope with the disease.

• KEY POINTS

• Issues vital for coping with chronic obstructive pulmonary disease (COPD), such as psychological well-being, stress and fatigue, are irregularly included in self-management education both in primary and specialised healthcare.

• Patient education provided by asthma/COPD nurses is more regular than patient education provided by other nurses.

• The distribution of work between doctors and nurses should be considered to ensure that there is no gap in COPD patients’ education.

     

Evaluation of the in vivo efficacy of topical tobramycin against Pseudomonas sinonasal biofilms

BACKGROUND: There is increasing evidence that bacterial biofilms are present within the sinonasal mucosa of patients with medically recalcitrant chronic rhinosinusitis. The antibiotic concentrations needed to eradicate biofilms are much higher than those commonly used and pose an increased risk for systemic side effects. Topical medications are an alternative approach to deliver high concentrations to the mucosa while limiting systemic side effects. This is the first study to evaluate the effects of a topical antibiotic on Pseudomonas biofilms in an animal model of sinusitis. METHODS: Pseudomonas sinusitis was established in nine rabbits. An irrigation catheter was placed within the lumen of the maxillary sinus, and the rabbits were irrigated with 7 days of normal saline or varying concentrations of tobramycin diluted in normal saline. Bacterial cfu were determined for nasal lavage fluid as well as physically disrupted mucosa, and scanning electron microscopy (SEM) of the mucosal surface was performed at the end of the study. RESULTS: Increasing concentrations of topical tobramycin resulted in the eradication of viable bacteria within the lumen of the sinus but did not eradicate Pseudomonas attached to the mucosa. SEM detected biofilms within the mucosa even in those rabbits treated with high concentrations of topical tobramycin. CONCLUSIONS: Bacterial biofilms attached to the sinonasal mucosa are resistant to topical saline and tobramycin irrigation. SEM was useful in the identification of biofilms, but did not provide a quantitative evaluation for efficacy of treatment.     

Health professionals’ perspectives of next of kin in the context of reablement

Aim: To describe health professionals’ perspectives of next of kin in the context of reablement.

Methods: A total of 49 health professionals from different organizational levels participated. Their ages, genders, experiences, and professions varied. A total of 10 focus group discussions were held in two municipalities. The data analysis was conducted using a constructivist grounded theory approach.

Results: The core category was identified as negotiating between themselves. Two categories captured the different dimensions of the core category: facing a dilemma with next of kin in reablement and ambiguous motives for collaborating with next of kin.

Conclusion: In collaboration with next of kin, it is important for health professionals to be aware of and manage the possible differences in expectations and opinions concerning reablement. Health professionals need to acknowledge that next of kin can be a source of support for older adults. They also need to take into consideration that next of kin may need support, information, and education associated with their roles as next of kin to older adults.

• Implications for rehabilitation

• Health professionals need to be aware of how they collaborate with next of kin and what they expect of them.

• There is a need for health professionals to find a routine in how next of kin can become partners in reablement without compromising the older adult’s autonomy.

• This study contributes to further awareness of the different roles of health professionals and next of kin regarding expectations of reablement.

• Health professionals may benefit from providing a more family-centred approach by taking into account that next of kin can be a resource in reablement. In addition, they need to take into consideration that next of kin also have their own needs and must be respected.

     

The Activity of Palliative Care Team Pharmacists in Designated Cancer Hospitals: A Nationwide Survey in Japan

ContextThe role of pharmacists in palliative care has become more important now that they are able to provide medication review, patient education, and advice to physicians about a patient's pharmacotherapy. However, there is little known about pharmacists' activity on palliative care teams.ObjectivesThe present study aimed to examine the clinical, educational, and research activities of pharmacists on palliative care teams and pharmacist-perceived contributions to a palliative care team or why they could not contribute.MethodsWe sent 397 questionnaires to designated cancer hospitals, and 304 responses were analyzed (response rate 77%).ResultsOf the pharmacists surveyed, 79% and 94% reported attending ward rounds and conferences, respectively. Half of the pharmacists provided information/suggestions to the team about pharmacology, pharmaceutical production, managing adverse effects, drug interactions, and/or rotation of drugs. In addition, 80% of the pharmacists organized a multidisciplinary conference on palliative care education. Furthermore, 60% of the pharmacists reported on palliative care research to a scientific society. Seventy percent of the pharmacists reported some level of contribution to a palliative care team, whereas 16% reported that they did not contribute, with the main perceived reasons for no contribution listed as insufficient time (90%) and/or staff (68%).ConclusionIn Japan, pharmacists exercise a moderate level of clinical activity on palliative care teams. Many pharmacists believe that they contribute to such a team and generally place more emphasis on their educational and research roles compared with clinical work.     

Facilitators and barriers to the use of service dogs: an exploratory study using the Theoretical Domains Framework

Abstract

Purpose: Given the scarcity of service dogs to help individuals with mobility impairments in the community, it is crucial to identify facilitators and obstacles to the acquisition and use of service dogs in order to optimize their use and have a positive impact on the lives of individuals with disabilities. The goal of this study was to describe perceived facilitators and barriers influencing the acquisition and use of service dog by owners and rehabilitation providers, including those who had and had not recommended service dogs.

Method: We conducted a phenomenological qualitative study involving in-depth interviews with nine service dog owners and 13 rehabilitation professionals in Canada. Our questionnaires were based on the Theoretical Domains Framework and the data were analyzed using a thematic content approach.

Results: Knowledge, beliefs about consequences, and environmental context and resources were the domains most frequently mentioned by both dog owners and rehabilitation professionals. While service dog owners placed greater importance on their belief in their capacity to get and use service dogs, rehabilitation professionals focussed more on their role and identity within the process.

Conclusion: Improving the knowledge of the availability and process of acquiring service dogs would be important for rehabilitation professions to improve the quality of life and functional capabilities of persons with disabilities.

• Implications for rehabilitation

• Identifying determinants of service dog acquisition and use can support proposed strategies to optimize the use of this assistive technology;

• Determinants of service dog acquisition and use are are different for dog owners and rehabilitation professionals, which suggest the need of tailored knowledge translation strategies;

• Knowledge, beliefs about consequences, and environmental context and resources were the categories of determinants perceived as being more influential on the process.

     

Cooperation of return-to-work professionals: the challenges of multi-actor work disability management

Purpose: This article explores which concrete factors hinder or facilitate the cooperation of return-to-work (RTW) professionals in a complex system of multiple stakeholders.

Method: The empirical material consists of in-depth interviews with 24 RTW professionals from various organizations involved in work disability management in Finland. The interviews were analyzed using thematic content analysis.

Results: The study revealed several kinds of challenges in the cooperation of the professionals. These were related to two partly interrelated themes: communication and distribution of responsibility. The most difficult problems were connected to the cooperation between public employment offices and other stakeholders. However, the study distinguished notable regional differences depending primarily on the scale of the local network. The main areas of improvement proposed by the interviewees were related to better networking of case managers and expansion of expertise.

Conclusions: The article argues for the importance of systematic networking and stresses the role of public employment services in the multi-actor management of work disabilities. The article contributes to existing work disability case management models by suggesting the employment administration system as an important component in addition to health care, workplace and insurance systems. The study also highlights the need for expansion of expertise in the field.

• Implications for Rehabilitation

• Cooperation between RTW professionals in public employment offices and other organizations involved in work disability management was considered inadequate.

• In order to improve the cooperation of RTW professionals, the stakeholders need to create more systematic ways of communication and networking with professionals in other organizations.

• There is a need to expand the expertise in work disability management and rehabilitation, partly by increasing the role of other professionals than physicians.

     

Encouraging post-stroke patients to be active seems possible: results of an intervention study with knowledge brokers

Purpose: Although physical activity and exercise for stroke patients is highly recommended for fast recovery, patients in hospitals and rehabilitation centres are insufficiently encouraged to be physically active. In this study, we investigated the impact of knowledge brokers (KBs), enterprising nurses and therapists, on health professionals’ (HP) performance to encourage stroke inpatients to be physically active. Method: This multicenter intervention study used a pre–post test design. Two or three KBs were trained in each stroke unit of 12 hospitals and 10 rehabilitation centres in The Netherlands. Questionnaires were completed by patients and HPs before and after the KB-intervention. The primary outcome was encouragement given by HPs to their patients to be physically active, as reported by patients and HPs. Results: After the KB-intervention, many more patients (48%; N=217) reported at least some encouragement by HPs to be physically active than before (26%; N=243, p<0.000). HPs (N=288) on an average reported encouraging patients more often after the intervention, but this difference was significant only for occupational therapists and KBs. Conclusions: Based on patient’s reports of HP behaviour, the KB-intervention appears effective since more patients felt encouraged to be physically active after the intervention compared to before. Replication of this study in an experimental design is needed to allow causal inferences.

• Implications for rehabilitation

• We advise rehabilitation teams to make use of knowledge brokers (KBs), since the KB-intervention was shown to increase the encouragement felt by stroke patients to be physically active.

• It seems worthwhile to involve physicians, nurses and patients’ families more frequently in efforts to encourage stroke patients to be physically active.

     

Therapeutic goals and treatment response evaluation in moderate to severe psoriasis: an experts opinion document

ObjectiveTo critically analyse and define therapeutic objectives, response to treatment evaluation and related decisions in psoriasis.MethodsExpert consensus meetings, a systematic and narrative reviews and a collaborative Delphi procedure were carried out. A steering committee from the Spanish Group of Psoriasis was established who based on the reviews generated a set of related statements. Subsequently, a group of 40 experts tested their agreement with the statements, through 3 Delphi rounds.ResultsWe found a great variability in clinical guidelines regarding to the definition of treatment goal and the response. In general, treatment failure was considered if a PASI50 is not achieved. The panel of experts agreed on (1) clearly differentiate between ideal and a realistic goals when establishing the therapeutic goal in moderate to severe psoriasis; (2) treatment goals should be in general established regardless of the type of drug for psoriasis; (3) treatment failure if PASI75 response is not reached; (4) an absolute PASI is in general preferred to the rate of PASI improvement from baseline; (5) disease characteristics, patients and physicians opinions/needs and treatment adherence influence treatment goals.ConclusionsA clear treatment decision making framework is vital to improve management of psoriasis.

KEY MESSAGES

• Psoriasis characteristics, patients and physicians opinions/needs and treatment adherence influence treatment goals.
• Different disease indexes could be used to assess treatment response but absolute PASI is preferred
• In general psoriasis treatment failure should be considered if PASI75 response is not reached

     

If a joint is hot it’s not the time: health professionals’ views on developing an intervention to promote physical activity in rheumatoid arthritis

Purpose: The study aimed to explore the views of health professionals on (i) physical activity in people who have rheumatoid arthritis (RA) and (ii) the design of an intervention to promote physical activity in this population.

Method: We used a qualitative methodology and conducted 14 interviews (rheumatologists n?=?7, physiotherapist n?=?4, clinical nurse specialists n?=?3). Interviews were transcribed verbatim and analyzed using thematic analysis.

Results: Three key themes were generated: “Personal opinions”, “Supporting physical activity” and “An ideal world”. Although health professionals viewed physical activity as important, recommending it to people who have RA was largely based on persons’ disease status rather than empirical evidence. Resources were highlight as a key challenge to interventions in clinical practice. Supporting physical activity through provision of information, goal setting and monitoring was also discussed.

Conclusion: Health professionals believe physical activity is important for people who have RA, although there is uncertainty regarding physical activity recommendations for this population. Thus, there is scope to increase health professionals’ knowledge of recent evidence. Views varied on how an intervention to promote physical activity should be delivered, but consideration of barriers to delivery in clinical practice is important.

• Implications for Rehabilitation

• Physical activity is an important aspect of disease management for people who have rheumatoid arthritis.

• Health professionals need to acknowledge the “mixed messages” received by people who have RA about being physically active thus further education for health professionals is suggested to standardize physical activity advice in clinical practice.

• Health professionals may benefit from education about behavior change theory and techniques.

• When designing future physical activity interventions consideration of the practical challenges of implementing research in a clinical setting is necessary.

     

Primary care guidelines: Senior executives’ views on changing health centre practices in hypertension treatment

Objective

To describe the adoption of the national Hypertension Guideline in primary care and to evaluate the consistency of the views of the health centre senior executives on the guideline''s impact on clinical practices in the treatment of hypertension in their health centres.

Design

A cross-sectional telephone survey.

Setting

All municipal health centres in Finland.

Subjects

Health centres where both the head physician and the senior nursing officer responded.

Main outcome measures

Agreement in views of the senior executives on the adoption of clinical practices as recommended in the Hypertension Guideline.

Results

Data were available from 143 health centres in Finland (49%). The views of head physicians and senior nursing officers on the adoption of the Hypertension Guideline were not consistent. Head physicians more often than senior nursing officers (44% vs. 29%, p < 0.001) reported that no agreements on recording target blood pressure in patient records existed. A similar discrepancy was seen in recording cardiovascular risk (64% vs. 44%, p < 0.001). Senior executives agreed best on the calibration of sphygmomanometers and the provision of weight-control group counselling.

Conclusions

Hypertension Guideline recommendations that require joint agreements between professionals are less often adopted than simple, precise recommendations. More emphasis on effective multidisciplinary collaboration is needed.     

Professionals’ views on the use of smartphone technology to support children and adolescents with memory impairment due to acquired brain injury

Purpose To identify from a health-care professionals’ perspective whether smartphones are used by children and adolescents with acquired brain injury as memory aids; what factors predict smartphone use and what barriers prevent the use of smartphones as memory aids by children and adolescents. Method A cross-sectional online survey was undertaken with 88 health-care professionals working with children and adolescents with brain injury. Results Children and adolescents with brain injury were reported to use smartphones as memory aids by 75% of professionals. However, only 42% of professionals helped their clients to use smartphones. The only factor that significantly predicted reported smartphone use was the professionals’ positive attitudes toward assistive technology. Several barriers to using smartphones as memory aids were identified, including the poor accessibility of devices and cost of devices. Conclusion Many children and adolescents with brain injury are already using smartphones as memory aids but this is often not facilitated by professionals. Improving the attitudes of professionals toward using smartphones as assistive technology could help to increase smartphone use in rehabilitation.

• Implications for Rehabilitation

• Smartphones could be incorporated into rehabilitation programs for young people with brain injury as socially acceptable compensatory aids.

• Further training and support for professionals on smartphones as compensatory aids could increase professionals’ confidence and attitudes in facilitating the use of smartphones as memory aids.

• Accessibility could be enhanced by the development of a smartphone application specifically designed to be used by young people with brain injury.

     

ICF profiling of patients with traumatic brain injury: an international professional survey

Abstract

Purpose: A worldwide internet survey was conducted (1) to identify problems of individuals with traumatic brain injury (TBI) addressed by health professionals and (2) to summarize these problems using the International Classification of Functioning, Disability and Health (ICF). Method: A pool of professionals involved in the TBI rehabilitation process that included physicians, nurses, physical therapists, occupational therapists, social workers and psychologists were surveyed to identify problems in functioning and contextual factors of individuals with TBI using open-ended questions. All answers were translated (“linked”) to the ICF based on established rules. The frequencies of the linked ICF categories were reported stratified based on context. Results: One-hundred thirty seven professionals from the six World Health Organization regions identified 5656 concepts. 92.66% could be linked to the ICF; 33.03% were related to the domain of body functions, 27.28% to activities and participation, 10.98% to structures and 21.38% to environmental factors. Conclusions: The complexity of TBI was described through the identification of a wide variety of ICF categories. ICF language proved to be a neutral framework allowing the comparison of answers between different professionals in different world regions.

• Implications for Rehabilitation

• People that suffered a traumatic brain injury (TBI) may have a variety of sequelae that impair functioning. The International Classification of Functioning, Disability and Health (ICF) can help in providing information regarding the identification of patients problems and needs as well as planning, implementing and coordinating the rehabilitation process.

• The ICF provides a frame of reference process illustrated as the rehabilitation cycle that can help during the rehabilitation process in goal setting bringing together the clinicians’ and patient’s perspectives in a patient oriented biopsychosocial approach.

• In the field of TBI rehabilitation, activity limitations and participation restrictions are broadly affected as reported by the professionals interviewed and highly influenced by cognitive and moreover behavioral problems.

     

Generalised anxiety disorder symptoms and utilisation of health care services. A cross-sectional study from the “Northern Finland 1966 Birth Cohort”

Objective: To analyse the utilization of health care services of people who tested positive for GAD compared to those who tested negative. Setting: A cross-sectional study from the Northern Finland 1966 Birth Cohort. Subjects: A total of 10,282 members followed from birth in a longitudinal study were asked to participate in a follow-up survey at the age of 46. As part of this survey they filled in questionnaries concerning health care utilization and their illness history as well as the GAD-7 screening tool. Althogether 5,480 cohort members responded to the questionnaries. Main outcome measures: Number of visits in different health care services among people who tested positive for GAD with the GAD-7 screening tool compared to those who tested negative. Results: People who tested positive for GAD had 112% more total health care visits, 74% more total physician visits, 115% more visits to health centres, 133% more health centre physician visits, 160% more visits to secondary care, and 775% more mental health care visits than those who tested negative. Conclusion: People with GAD symptoms utilize health care services more than other people.

• Key Points

• Generalised anxiety disorder (GAD) is a common but poorly identified mental health problem in primary care.

• People who tested positive for GAD utilise more health care services than those who tested negative.

• About 58% of people who tested positive for GAD had visited their primary care physician during the past year.

• Only 29% of people who tested positive for GAD had used mental health services during the past year.

     

The Environment of Care Model: a paradigm shift in comprehensive breast care

Abstract

Knowing one’s own role is a key collaboration competency for postgraduate trainees in the Canadian competency framework (CanMEDS®). To explore methods to teach collaborative competency to internal medicine postgraduate trainees, baseline role knowledge of the trainees was explored. The perceptions of roles (self and others) at patient discharge from an acute care internal medicine teaching unit amongst 69 participants, 34 physicians (25 internal medicine postgraduate trainees and 9 faculty physicians) and 35 health care professionals from different professions were assessed using an adapted previously validated survey (Jenkins et al., 2001). Internal medicine postgraduate trainees agreed on 8/13 (62%) discharge roles, but for 5/13 (38%), there was a substantial disagreement. Other professions had similar lack of clarity about the postgraduate internal medicine residents’ roles at discharge. The lack of interprofessional and intraprofessional clarity about roles needs to be explored to develop methods to enhance collaborative competence in internal medicine postgraduate trainees.