Health Care Students’ Differing Conceptions of Expertise: A Challenge for Inter-Professional Care

The aim of the study was to examine do health care students, who study at different programs, value similar expert qualities. To investigate this issue, a questionnaire was administered among health care students in a Finnish polytechnic (two cohorts, total n = 466), consisting of a scale for rating the importance of different expert qualities. The questionnaire resulted in the following dimensions of the conceptions of expertise: (1) social skills, (2) scientific skills, (3) innovativeness, (4) continuing self-development, and (5) problem-solving skills. Also the Inventory of General Study Orientations (IGSO) was applied to analyse possible motivational explanations for different conceptions of expertise. In addition to the scales, an open-ended writing task was used to explore in depth students’ conceptions of expertise. It appeared that study orientations were a minor factor in the study, while study environment (study programs) clearly differentiated students’ conceptions of expertise. Thus, the study argues that health care students’ conceptions of expertise are constituted mainly on domain-specific bases and that students who graduate from different programs may possess very diverse ideas about their profession. Consequently, different conceptions captured during the education form a major challenge for inter-professional care later in work-life. This phenomenon should be taken into account when organising health care education.     

Accuracy of health examination results self-reported by Japanese participants

BACKGROUND: We evaluated the accuracy of self-reported health examination results by participants regarding their most recent public health examination by comparing their answers to the medical records in order to determine individual factors related to self-reporting accuracy. METHODS: The study was conducted at Settsu City in Osaka prefecture, Japan, in 1998 with 3570 participants who underwent general health examinations conducted by the municipal government. All participants were interviewed regarding their lifestyle as well as health guidance given at their previous examination, after which their answers were compared with the data from their medical records. The adjusted odds ratio (OR) for providing accurate self-reporting was calculated by multivariate logistic analyses. RESULTS: The frequency of accurate self-reporting was 49.4% and the overall Kappa value was 0.34. The OR for accurate self-reporting was lowest for those who have a poor lifestyle compared with those who had a good lifestyle. CONCLUSION: The accuracy of self-reported health examination results was poor. We concluded that information based on self-reported results of a health examination must be considered carefully. Further, lifestyle was found to be associated with the ability to accurately recall. Thus, methods for providing guidance to individuals with a poor life style must be carefully examined.     

Facilitating good process in primary palliative care: does the Gold Standards Framework enable quality performance?

BACKGROUND: Palliative care is an important, complex aspect of primary care, requiring a multidisciplinary approach. The Gold Standards Framework (GSF), a programme used by over 3,000 UK practices, aims to facilitate high-quality palliative care through the introduction of systematic clinical and organizational processes. Quality payments for palliative care are available to UK practices which maintain registers and hold multidisciplinary meetings. OBJECTIVES: To explore the effectiveness and sustainability of the implementation of GSF at practice level. METHODS: The study followed a qualitative comparative case study design using in-depth interviews and observational data with 15 practices participating in GSF, from three areas differing in socio-geography. Semi-structured interviews (total 45) with GPs, community nurses and practice managers were supplemented by observation of practice meetings and systems, to provide contextual insights. Transcribed interviews were analysed using a thematic matrix approach and comparisons were made within and between practices. Practices were identified on a continuum of performance (high, medium and minimal) according to the evidence of functioning in palliative care-related activity. RESULTS: Considerable variation existed between practices in both the extent of palliative care-related processes and the effectiveness of inter-professional communication. High-performing practices displayed a clear-shared purpose for palliative care with effective communication, whereas minimal performing practices demonstrated little utilization of basic GSF processes and deficiencies in inter-professional communication. CONCLUSION: Effective palliative care requires good team relationships and robust processes. While GSF can enable such improvements, quality measures focusing on processes alone are inadequate to distinguish good practice, questioning the effectiveness of current quality measures in UK general practice.     

Low yield of population-based screening for Type 2 diabetes in the Netherlands: the ADDITION Netherlands study

BACKGROUND: About 10 years ago, it was estimated that half of all people with diabetes were unrecognized. Since then, according to the national guidelines, case finding for diabetes in general practice has become common in the Netherlands, resulting in a substantial increase of the prevalence of known diabetes. Nevertheless, the need for population-based screening is advocated, especially by the national federation of diabetes patients. OBJECTIVE: To evaluate the efficiency of population-based screening for Type 2 diabetes. METHODS: From 2002 to 2004, we performed a four-step screening procedure [questionnaire, random glucose measurement, fasting glucose measurement and oral glucose tolerance test (OGTT)] and a three-step procedure (without random glucose measurement) in 79 general practices in the southwestern region of the Netherlands. RESULTS: A total of 56 978 non-diabetic subjects, aged 50-70 years, were asked to complete the questionnaire. Those with a score above threshold underwent further glucose testing. Eventually, 586 participants (1.0%) were diagnosed with Type 2 diabetes (in four-step procedure 285 subjects and in three-step procedure 301). Impaired glucose regulation was assessed in 1011 participants (1.8%). Dropout rate in the screening programme among participants who should undergo an OGTT was 23.4%. The risk score was higher if glucose metabolism was more disturbed. CONCLUSION: In the Netherlands, the yield of population-based screening is low. The dropout among high-risk individuals was high. Given the decreasing prevalence of undiagnosed diabetes and the possibility of opportunistic screening on a continuous basis, opportunistic screening for diabetes might be more appropriate than population-based screening. Further research on this topic is needed.     

Logistic support service improves processes and outcomes of diabetes care in general practice

BACKGROUND: Guidelines for type 2 diabetes care in general practice are well known and accepted, but the implementation falls short. OBJECTIVE: To implement these guidelines by introducing a diabetes support service (DSS) to support the care delivered by the GP. METHODS: A controlled, non-randomised study with delayed intervention in the control group; 78 GPs (n=51 for the intervention and n=21 for the control group) in the south of the Netherlands and 613 of their type 2 diabetic patients participated. Data were collected on the frequency, content and results of the check-ups (fasting blood glucose, HbA1c, cholesterol, cholesterol/HDL ratio, triglycerides, creatinine, blood pressure, fundus photography, foot examination, body mass index and smoking status) for 3 years. The year before signing up with the DSS was taken for the pre-measurements and after 2 years of DSS the post-measurements took place. The effect of the DSS was analysed in a mixed model with repeated measurement covariance structure. RESULTS: At baseline the intervention and control group did not differ in control frequency and outcome (HbA1c). After the intervention the percentage of patients that attended four or more quarterly check-ups (with at least testing of fasting blood glucose or HbA1c) increased from 59 to 78%. In contrast, the frequency of check-ups in the control group remained constant. This effect was significant. The HbA1c remained the same in the intervention group while there was a significant deterioration in the HbA1c in the control group. CONCLUSION: Simple logistic support by the DSS proved to have the capacity to implement type 2 diabetes guidelines in general practice.     

Social disparities in diabetes care: a general population study in Denmark

Objective: We investigated the association between socioeconomic factors and the attainment of treatment goals and pharmacotherapy in patients with type 2 diabetes in Denmark.

Design: A cross-sectional population study.

Setting: The municipality of Naestved, Denmark.

Subjects: We studied 907 patients with type 2 diabetes identified from a random sample of 21,205 Danish citizens.

Main outcome measures: The proportion of patients who were not achieving goals for diabetes care based on their HbA_1c, LDL-cholesterol, blood pressure, and lifestyle, and the proportion of patients who were treated with antihypertensive and cholesterol- and glucose-lowering medication.

Methods: We investigated the association of the socioeconomic factors such as age, gender, education, occupation, income, and civil status and attainment of treatment goals and pharmacotherapy in logistic regression analyses. We investigated effect modification of cardiovascular disease and kidney disease.

Results: Middle age (40–65 years), low education level (i.e. basic schooling), and low household income (i.e. less than 21,400 € per year) were associated with nonattainment of goals for diabetes care. The association of socioeconomic factors with attainment of individual treatment goals varied. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Socioeconomic factors were not associated with treatment goals for hyperglycemia. Socioeconomic factors were inconsistently associated with pharmacotherapy. There was no difference in contacts to general practitioners according to SES.

Conclusions: In a country with free access to health care, the socioeconomic factors such as middle age, low education, and low income were associated with nonattainment of goals for diabetes care.

• KEY POINTS

• Middle age, low education, and low income were associated with nonattainment of goals for diabetes care, especially for lifestyle goals.

• Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure.

• Association of socioeconomic factors with pharmacotherapy was inconsistent.

     

七氟醚和异丙酚麻醉对应激反应及血流动力学的影响

目的 探讨异丙酚和七氟醚麻醉对应激反应及血流动力学的影响,为手术提供一种合理的麻醉方法.方法Ⅰ组20例异丙酚静脉诱导,异丙酚静脉持续泵入4-8μgkg/h维持麻醉;Ⅱ组20例七氟醚诱导,七氟醚持续吸入1%-2%维持麻醉.观测两组病人不同时期的血糖、皮质醇及SBP、DBP、HR、SpO2的变化.结果Ⅰ组术中SBP、DBP比Ⅱ组明显降低（P＜0.05）;术中,术毕Ⅰ组皮质醇明显高于Ⅱ组（P＜0.01）;术毕时Ⅰ组血糖明显高于Ⅱ组（P＜0.01）.结论 七氟醚吸入麻醉比异丙酚静脉麻醉应激反应小,血流动力学变化小,更适合于麻醉的选择.