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Winkler K, Gerlach N, Donner-Banzhoff N, Berberich A, Jung-Henrich J, Schlößler K. Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds. BMC PRIMARY CARE 2023; 24:110. [PMID: 37131137 PMCID: PMC10152784 DOI: 10.1186/s12875-023-02064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 04/18/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Chest pain is a frequent consultation issue in primary care, with coronary artery disease (CAD) being a serious potential cause. Primary care physicians (PCPs) assess the probability for CAD and refer patients to secondary care if necessary. Our aim was to explore PCPs' referral decisions, and to investigate determinants which influenced those decisions. METHODS PCPs working in Hesse, Germany, were interviewed in a qualitative study. We used 'stimulated recall' with participants to discuss patients with suspected CAD. With a sample size of 26 cases from nine practices we reached inductive thematic saturation. Interviews were audio-recorded, transcribed verbatim and analyzed by inductive-deductive thematic content analysis. For the final interpretation of the material, we used the concept of decision thresholds proposed by Pauker and Kassirer. RESULTS PCPs reflected on their decisions for or against a referral. Aside from patient characteristics determining disease probability, we identified general factors which can be understood as influencing the referral threshold. These factors relate to the practice environment, to PCPs themselves and to non-diagnostic patient characteristics. Proximity of specialist practice, relationship with specialist colleagues, and trust played a role. PCPs sometimes felt that invasive procedures were performed too easily. They tried to steer their patients through the system with the intent to avoid over-treatment. Most PCPs were unaware of guidelines but relied on informal local consensus, largely influenced by specialists. As a result, PCPs gatekeeping role was limited. CONCLUSIONS We could identify a large number of factors that impact referral for suspected CAD. Several of these factors offer possibilities to improve care at the clinical and system level. The threshold model proposed by Pauker and Kassirer was a useful framework for this kind of data analysis.
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Affiliation(s)
- Katja Winkler
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany.
| | - Navina Gerlach
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Anika Berberich
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Jutta Jung-Henrich
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
| | - Kathrin Schlößler
- Department of General Practice/Family Medicine, University Marburg, Karl-Von-Frisch-Str. 4, 35043, Marburg, Germany
- Institute of General Practice and Family Medicine (AM RUB), Ruhr University, Bochum, Germany
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Joseph JW, Leventhal EL, Grossestreuer AV, Chen PC, White BA, Nathanson LA, Elhadad N, Sanchez LD. Machine Learning Methods for Predicting Patient-Level Emergency Department Workload. J Emerg Med 2023; 64:83-92. [PMID: 36450614 DOI: 10.1016/j.jemermed.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/19/2022] [Accepted: 10/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Work Relative Value Units (wRVUs) are a component of many compensation models, and a proxy for the effort required to care for a patient. Accurate prediction of wRVUs generated per patient at triage could facilitate real-time load balancing between physicians and provide many practical operational and clinical benefits. OBJECTIVE We examined whether deep-learning approaches could predict the wRVUs generated by a patient's visit using data commonly available at triage. METHODS Adult patients presenting to an urban, academic emergency department from July 1, 2016-March 1, 2020 were included. Deidentified triage information included structured data (age, sex, vital signs, Emergency Severity Index score, language, race, standardized chief complaint) and unstructured data (free-text chief complaint) with wRVUs as outcome. Five models were examined: average wRVUs per chief complaint, linear regression, neural network and gradient-boosted tree on structured data, and neural network on unstructured textual data. Models were evaluated using mean absolute error. RESULTS We analyzed 204,064 visits between July 1, 2016 and March 1, 2020. The median wRVUs were 3.80 (interquartile range 2.56-4.21), with significant effects of age, gender, and race. Models demonstrated lower error as complexity increased. Predictions using averages from chief complaints alone demonstrated a mean error of 2.17 predicted wRVUs per visit (95% confidence interval [CI] 2.07-2.27), the linear regression model: 1.00 wRVUs (95% CI 0.97-1.04), gradient-boosted tree: 0.85 wRVUs (95% CI 0.84-0.86), neural network with structured data: 0.86 wRVUs (95% CI 0.85-0.87), and neural network with unstructured data: 0.78 wRVUs (95% CI 0.76-0.80). CONCLUSIONS Chief complaints are a poor predictor of the effort needed to evaluate a patient; however, deep-learning techniques show promise. These algorithms have the potential to provide many practical applications, including balancing workloads and compensation between emergency physicians, quantify crowding and mobilizing resources, and reducing bias in the triage process.
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Affiliation(s)
- Joshua W Joseph
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Evan L Leventhal
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Anne V Grossestreuer
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Benjamin A White
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Larry A Nathanson
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Noémie Elhadad
- Departments of Biomedical Informatics and Computer Science, Columbia University, New York, New York
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Stolpe S, Scholz C, Stang A, Böger C, Jung B, Kowall B, Blume C. [High patient unawareness for chronic kidney disease even in later stages - but why is it more frequent in women than in men?]. Dtsch Med Wochenschr 2022; 147:e70-e81. [PMID: 35926520 PMCID: PMC9420553 DOI: 10.1055/a-1819-0870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Chronic kidney failure (CKD) is as common as diabetes or coronary heart disease in a population aged 40 years and older. Although CKD increases the risk of secondary diseases or premature death, patients with CKD are often unaware of their disease. In a recent analysis of German data, unawareness CKD was higher in women than in men. METHODS Baseline data from 2010 of 3,305 CKD patients from German cohort studies and registries were analyzed. Stage 1-4 CKD was defined by eGFR (estimated glomerular filtration rate) and albumin-creatinine ratio according to the KDIGO-guideline. Patient knowledge of CKD was coded according to self-report. The proportion of patients without knowledge of CKD and the sex-specific proportion difference (each with 95 % confidence interval) were calculated according to CKD stages and additional comorbidities (diabetes, hypertension, anemia, and cardiovascular disease). In addition, the prevalence ratio (PR) for not knowing about CKD was estimated for women compared to men crude and adjusted for age and other risk factors. RESULTS Women were less likely than men to know about their CKD in all subgroups studied by age, CKD stage, and comorbidities. The proportion difference for CKD awareness increased with higher CKD stage and was 21 percentage points (7.6; 34.6) at the expense of women in CKD stage 4. Among patients with CKD stage 3b and concomitant grade 2 hypertension, 61 % of women versus 45 % of men were unaware of their disease. The PR for CKD unawareness in women compared with men in the fully adjusted model increased from 1.08 (1.00; 1.16) in CKD stage 3a to 1.75 (1.14; 2.68) in CKD stage 4. CONCLUSION Despite the presence risk factors that necessitate monitoring of renal function, less than half of patients know they have CKD stage 3b or 4. Women are less likely to be aware of their CKD in all subgroups. Possible causes are gender-related differences in primary health care (gender bias) or in patient-doctor communication.
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Affiliation(s)
- Susanne Stolpe
- Universitätsklinikum Essen, Institut für Medizinische Informatik, Biometrie und Epidemiologie
| | | | - Andreas Stang
- Universitätsklinikum Essen, Institut für Medizinische Informatik, Biometrie und Epidemiologie.,School of Public Health, Department of Epidemiology, Boston, USA
| | - Carsten Böger
- Kliniken Südostbayern AG, Innere Medizin, Nephrologie, Diabetologie und Rheumatologie Traunstein
| | - Bettina Jung
- Kliniken Südostbayern AG, Innere Medizin, Nephrologie, Diabetologie und Rheumatologie Traunstein
| | - Bernd Kowall
- Universitätsklinikum Essen, Institut für Medizinische Informatik, Biometrie und Epidemiologie
| | - Cornelia Blume
- Leibniz Universität Hannover, Institut für Technische Chemie, Hannover
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Ballering AV, Muijres D, Uijen AA, Rosmalen JGM, Olde Hartman TC. Sex differences in the trajectories to diagnosis of patients presenting with common somatic symptoms in primary care: an observational cohort study. J Psychosom Res 2021; 149:110589. [PMID: 34385033 DOI: 10.1016/j.jpsychores.2021.110589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Little insight exists into sex differences in diagnostic trajectories for common somatic symptoms. This study aims to quantify sex differences in the provided primary care diagnostic interventions for common somatic symptoms, as well as the consequences hereof for final diagnoses. METHODS In this observational cohort study, we used real-world clinical data from the Dutch Family Medicine Network (N = 34,268 episodes of care related to common somatic symptoms; 61,4% female). The association between patients' sex on the one hand, and diagnostic interventions and disease diagnoses on the other hand, were assessed using multilevel multiple logistic regression analyses. Structural equation modelling was used to estimate a mediation model with multiple parallel mediators to assess whether the fewer disease diagnoses given to female patients were mediated by the fewer diagnostic interventions female patients receive, compared to male patients. RESULTS Women received fewer physical examinations (OR = 0.84, 95%CI = 0.79-0.89), diagnostic imaging (OR = 0.92, 95%CI = 0.84-0.99) and specialist referrals (OR = 0.85, 95%CI = 0.79-0.91) than men, but more laboratory diagnostics (OR = 1.27, 95%CI = 1.19-1.35). Women received disease diagnoses less often than men for their common somatic symptoms (OR = 0.94, 95%CI = 0.89-0.98). Mediation analysis showed that the fewer disease diagnosis in female patients were mediated by the fewer diagnostic interventions conducted in women compared to men. CONCLUSION This study shows that sex inequalities are present in primary care diagnostic trajectories of patients with common somatic symptoms and that these lead to unequal health outcomes in terms of diagnoses between women and men. FPs have to be aware of these inequalities to ensure equal high-quality care for all patients.
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Affiliation(s)
- Aranka V Ballering
- University of Groningen, University Medical Center of Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, the Netherlands, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands.
| | - Daan Muijres
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands. P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Annemarie A Uijen
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands. P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Judith G M Rosmalen
- University of Groningen, University Medical Center of Groningen, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, the Netherlands, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands.
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands. P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
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Øyeflaten I, Maeland S, Haukenes I. Independent medical evaluation of general practitioners' follow-up of sick-listed patients: a cross-sectional study in Norway. BMJ Open 2020; 10:e032776. [PMID: 32193258 PMCID: PMC7202711 DOI: 10.1136/bmjopen-2019-032776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES The study was designed to examine the sufficiency of general practitioners' (GPs) follow-up of patients on sick leave, assessed by independent medical evaluators. DESIGN Cross-sectional study SETTING: Primary health care in the Western part of Norway. The study reuses data from a randomised controlled trial-the Norwegian independent medical evaluation trial (NIME trial). PARTICIPANTS The intervention group in the NIME trial: Sick-listed workers having undergone an independent medical evaluation by an experienced GP at 6 months of unremitting sick leave (n=937; 57% women). In the current study, the participants were distributed into six exposure groups defined by gender and main sick leave diagnoses (women/musculoskeletal, men/musculoskeletal, women/mental, men/mental, women/all other diagnoses and men/all other diagnoses). OUTCOME MEASURE The independent medical evaluators assessment (yes/no) of the sufficiency of the regular GPs follow-up of their sick-listed patients. RESULTS Estimates from generalised linear models demonstrate a robust association between men with mental sick leave diagnoses and insufficient follow-up by their regular GP first 6 months of sick leave (adjusted relative risk (RR)=1.8, 95% CI=1.15-1.68). Compared with the reference group, women with musculoskeletal sick leave diagnoses, this was the only significant finding. Men with musculoskeletal diagnoses (adjusted RR=1.4, 95% CI=0.92-2.09); men with other diagnoses (adjusted RR=1.0, 95% CI=0.58-1.73); women with mental diagnoses (adjusted RR=1.2, 95% CI=0.75-1.77) and women with other diagnoses (adjusted RR=1.3, 95% CI=0.58-1.73). CONCLUSIONS Assessment by an independent medical evaluator showed that men with mental sick leave diagnoses may be at risk of insufficient follow-up by their GP. Efforts should be made to clarify unmet needs to initiate relevant actions in healthcare and work life. Avoiding marginalisation in work life is of the utmost importance. TRIAL REGISTRATION NUMBER NCT02524392; Post-results.
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Affiliation(s)
- Irene Øyeflaten
- Norwegian National Advisory Unit on Occupational Rehabilitation, Rauland, Norway
- NORCE Norwegian Research Centre AS, Bergen, Norway
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van der Meer MG, Appelman Y, Rutten KHG, van der Graaf Y, Nathoe HM, Doevendans PA, Smit M, Verheij E, Botermans A, Rutten FH. Are there gender disparities in symptom presentation or triage of patients with chest discomfort at primary care out-of-hours services? An observational study. BMJ Open 2019; 9:e031613. [PMID: 31748303 PMCID: PMC6886986 DOI: 10.1136/bmjopen-2019-031613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Previous hospital-based studies have suggested delayed recognition of acute coronary syndrome (ACS) in women. We wanted to assess differences in symptom presentation or triage among women and men who contacted primary care out-of-hours services (OHS) for chest discomfort. DESIGN Retrospective observational study. SETTING Primary care OHS. PARTICIPANTS 276 women and 242 men with chest discomfort who contacted a primary care OHS in the Netherlands in 2013 and 2014. MAIN OUTCOME MEASURES Differences between women and men regarding symptom presentation and urgency allocation. RESULTS 8.4% women and 14.0% men had ACS. Differences in symptoms between patients with and without ACS were in general small, for both women and men. In women with ACS compared with women without ACS, mean duration of telephone calls was discriminative; 5.22 (SD 2.53) vs 7.26 (SD 3.11) min, p value=0.003. In men, radiation of pain (89.3% vs 54.9%, p value=0.011) was discriminative for ACS, and stabbing chest pain (3.7% vs 24.0%, p value=0.014) for absence of ACS . Women and men with chest discomfort received similar high urgency allocation (crude and adjusted OR after correction for ACS and age; 1.03 (95% CI 0.72 to 1.48) and 1.04 (95% CI 0.72 to 1.52), respectively). Women with ACS received a high urgency allocation in 22/23 (95.7%) and men with ACS in 30/34 (88.2%), p value=0.331. CONCLUSIONS Discriminating ACS in patients with chest discomfort who contacted primary care OHS is difficult in both women and men. Women and men with chest discomfort received similar high urgency allocation.
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Affiliation(s)
- Manon G van der Meer
- Cardiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Yolande Appelman
- Amsterdam University Medical Centre, Location VU Medical Centre, VU University, Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karlijn H G Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Hendrik M Nathoe
- Cardiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Cardiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Michelle Smit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emmy Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anne Botermans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Clerc Liaudat C, Vaucher P, De Francesco T, Jaunin-Stalder N, Herzig L, Verdon F, Favrat B, Locatelli I, Clair C. Sex/gender bias in the management of chest pain in ambulatory care. ACTA ACUST UNITED AC 2019; 14:1745506518805641. [PMID: 30370833 PMCID: PMC6300868 DOI: 10.1177/1745506518805641] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective: Cardiovascular diseases (CVD) are the main cause of death worldwide and despite a higher prevalence in men, mortality from CVD is higher among women. Few studies have assessed sex differences in chest pain management in ambulatory care. The objective of this post hoc analysis of data from a prospective cohort study was to assess sex differences in the management of chest pain in ambulatory care. Setting: We used data from the Thoracic Pain in Community cohort study that was realized in 58 primary care practices and one university ambulatory clinic in Switzerland. Participants: In total, 672 consecutive patients aged over 16 years attending a primary care practice or ambulatory care clinic with a complaint of chest pain were included between February and June 2001. Their mean age was 55.2 years and 52.5% were women. Main outcome measures: The main outcome was the proportion of patients referred to a cardiologist at 12 months follow-up. A panel of primary care physicians assessed the final diagnosis retained for chest pain at 12 months. Results: The prevalence of chest pain of cardiovascular origin (n = 108, 16.1%) was similar for men and women (17.5% vs 14.8%, respectively, p = 0.4). Men with chest pain were 2.5 times more likely to be referred to a cardiologist than women (16.6% vs 7.4%, odds ratio: 2.49, 95% confidence interval: 1.52–4.09). After adjustment for the patients’ age and cardiovascular disease risk factors, the estimates did not significantly change (odds ratio: 2.30, 95% confidence interval: 1.30–3.78). Conclusion: Although the same proportion of women and men present with a chest pain of cardiovascular origin in ambulatory care, there is a strong sex bias in their management. These data suggest that effort must be made to assure equity between men and women in medical care.
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Affiliation(s)
- Christelle Clerc Liaudat
- 1 Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Paul Vaucher
- 2 Unit of Traffic Medicine and Psychology, University Centre of Legal Medicine, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.,3 School of Health Sciences, University of Applied Sciences and Arts Western Switzerland (HES-SO), Fribourg, Switzerland
| | - Tommaso De Francesco
- 1 Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Nicole Jaunin-Stalder
- 1 Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland.,4 Cabinet Médical de Cugy, Cugy, Switzerland
| | - Lilli Herzig
- 5 Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | - François Verdon
- 5 Institute of Family Medicine, University of Lausanne, Lausanne, Switzerland
| | - Bernard Favrat
- 1 Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Isabella Locatelli
- 1 Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Carole Clair
- 1 Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
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Biesemans L, Cleef LE, Willemsen RTA, Hoorweg BBN, Renier WS, Buntinx F, Glatz JFC, Dinant GJ. Managing chest pain patients in general practice: an interview-based study. BMC FAMILY PRACTICE 2018; 19:80. [PMID: 29859536 PMCID: PMC5985055 DOI: 10.1186/s12875-018-0771-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/21/2018] [Indexed: 11/20/2022]
Abstract
Background Assessment of chest pain in general practice is challenging. General practitioners (GPs) often feel uncertainty when dealing with chest pain. The role of new diagnostic tools is yet unclear. Therefore, we aimed to learn: (1) whether or not GPs experience a change in incidence and presentation of chest pain, (2) how GPs deal with uncertainty, and (3) which thoughts, demands and doubts concerning new diagnostic tools occur. Methods Semi-structured, face to face interview based study, aiming at six main subjects: experienced changes in prevalence of chest pain, the management of chest pain patients, dealing with uncertainty, the GPs’ approach in referring chest pain patients, GPs’ attitude towards ‘unnecessary’ referrals, and the GPs’ suggestions for improving the management of chest pain patients. Results 145 GPs in Belgium and the Netherlands were invited to participate, 27 (15 Flemish and 12 Dutch) GPs were interviewed. Data saturation was reached. The number of patients having an acute coronary syndrome among chest pain patients is decreasing, whereas the presentation of atypical complaints increases, together leading to more uncertainty. GPs rely on their own judgment above all, and desire new diagnostic tools only when these tools are of proven added value. Conclusion The incidence of chest pain in general practice is not decreasing according to the GPs. However, the presentation of chest pain is changing. GPs feel relatively comfortable with referring a considerable number of chest pain patients without ACS, as over-referral is safe. Uncertainty is regarded as a substantial element of their profession. New diagnostic tools are awaited with cautiousness. Electronic supplementary material The online version of this article (10.1186/s12875-018-0771-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leen Biesemans
- Department of Family Medicine, Catholic University Leuven, Leuven, Belgium
| | - Lotte E Cleef
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands
| | - Robert T A Willemsen
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands.
| | - Beatrijs B N Hoorweg
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands
| | - Walter S Renier
- Department of Family Medicine, Catholic University Leuven, Leuven, Belgium
| | - Frank Buntinx
- Department of Family Medicine, Catholic University Leuven, Leuven, Belgium.,Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands
| | - Jan F C Glatz
- Department of Genetics & Cell Biology, Maastricht University, Maastricht, the Netherlands
| | - Geert-Jan Dinant
- Department of Family Medicine, Maastricht University, P. Debyeplein 1, (PO box 616), Maastricht, 6200, MD, the Netherlands
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Parvand M, Rayner-Hartley E, Sedlak T. Recent Developments in Sex-Related Differences in Presentation, Prognosis, and Management of Coronary Artery Disease. Can J Cardiol 2018; 34:390-399. [DOI: 10.1016/j.cjca.2018.01.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/09/2018] [Accepted: 01/09/2018] [Indexed: 12/17/2022] Open
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Briones-Vozmediano E, Öhman A, Goicolea I, Vives-Cases C. "The complaining women": health professionals' perceptions on patients with fibromyalgia in Spain. Disabil Rehabil 2017; 40:1679-1685. [PMID: 28385050 DOI: 10.1080/09638288.2017.1306759] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study is twofold: (1) to explore health service providers' perceptions regarding fibromyalgia patients in Spain and (2) to analyze possible consequences of these perceptions in terms of how health service providers construct the disease and treat their patients. DESIGN Qualitative study. SUBJECTS/PATIENTS Twelve health service providers (eight men, four women) involved in the care of fibromyalgia patients. Providers were from different disciplines and included general practitioners, rheumatologists, occupational doctors, psychologists, psychiatrists, physiotherapists and behavioral specialists from Spain. METHOD We performed individual semistructured interviews, which were recorded and transcribed to conduct a qualitative content analysis supported by Atlas.ti-7. RESULTS We identified three categories from the interviews: (1) the fibromyalgia patient prototype: the complaining woman, (2) fibromyalgia is considered a women's health issue, but male patients are a privileged minority, and (3) health professionals' attitudes toward fibromyalgia patients: are they really suffering or pretending? CONCLUSION The uncertainty surrounding fibromyalgia together with the fact that those affected are primarily women, seem to influence professional practice in terms of lack of recognition of Fibromyalgia as a severe disease. Increased training of all health professionals is essential to improving the support and attention given to patients suffering from fibromyalgia. Implications for rehabilitation Fibromyalgia • In order to improve fibromyalgia patients´ attention, health providers should learn how to assist patients without prejudices. • Training programs for health providers should include sensitization about the severity of fibromyalgia. • Health providers should be aware of the existence of stereotypes about women suffering from fibromyalgia. • Fibromyalgia protocols should give skills to health providers to avoid offering a gender-biased attention to patients.
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Affiliation(s)
- Erica Briones-Vozmediano
- a Faculty and Department of Nursing and Physiotherapy , University of Lleida , Lleida , Spain.,b Public Health Research Group of Alicante University , Alicante , Spain
| | - Ann Öhman
- d Umeå Center for Gender Studies, Umeå University , Umeå , Sweden.,e Epidemiology and Global Health, Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Isabel Goicolea
- b Public Health Research Group of Alicante University , Alicante , Spain.,e Epidemiology and Global Health, Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Carmen Vives-Cases
- b Public Health Research Group of Alicante University , Alicante , Spain.,c Community Nursing, Preventive Medicine and Public Health and History of Science Department. Alicante University , Alicante , Spain.,f Centre for Biomedical Research on Epidemiology and Public Health. CIBERESP , Barcelona , Spain
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Wiklund M, Fjellman-Wiklund A, Stålnacke BM, Hammarström A, Lehti A. Access to rehabilitation: patient perceptions of inequalities in access to specialty pain rehabilitation from a gender and intersectional perspective. Glob Health Action 2016; 9:31542. [PMID: 27569592 PMCID: PMC5002397 DOI: 10.3402/gha.v9.31542] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 07/12/2016] [Accepted: 07/15/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Long-term musculoskeletal pain is common, particularly among women. Pain conditions are a concern in primary health care, and people with severe and complex pain are referred to specialty health care. There is gender bias in access, counselling, assessment, and treatment of long-term pain. OBJECTIVE This study explores patient accounts and perceptions about important (social) factors for accessing specialised pain rehabilitation from gender and intersectional equality perspectives. We aimed to identify potential biases and inequalities in accessing rehabilitation resources at a specialised rehabilitation clinic. DESIGN Individual semi-structured interviews were conducted with 10 adults after an assessment or completion of a specialised rehabilitation programme in northern Sweden. Qualitative content analysis was used to explore patients' perceptions of important factors for accessing rehabilitation. RESULTS One main theme was formulated as Access to rehab - not a given. Three categories of perceived inequality were demonstrated: power of gender, power of social status, and power of diagnosis. Participants perceived rehabilitation as a resource that is not equally available, but dependent on factors such as gender, socio-economic status, ability to work, ethnicity, or age, and more subtle aspects of social status and habitus (e.g. appearance, fitness, and weight). The character of diagnosis received (medical versus psychiatric or social) was also noted. CONCLUSIONS It is crucial that professionals are aware of how potential inequalities related to gender, social status, and diagnosis, and their intersections, can be created, perceived, and have influence on the processes of assessment and treatment. Reduction of social determinants of health and biases remain important within global, national, and local contexts.
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Affiliation(s)
- Maria Wiklund
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- Department of Public Health and Clinical Medicine, Social Medicine, Umeå University, Umeå, Sweden;
| | - Anncristine Fjellman-Wiklund
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
| | - Britt-Marie Stålnacke
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Anne Hammarström
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- Department of Public Health and Clinical Medicine, Social Medicine, Umeå University, Umeå, Sweden
| | - Arja Lehti
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- Department of Clinical Sciences, Professional Development, Umeå University, Umeå, Sweden
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Hammarström A, Wiklund M, Stålnacke BM, Lehti A, Haukenes I, Fjellman-Wiklund A. Developing a Tool for Increasing the Awareness about Gendered and Intersectional Processes in the Clinical Assessment of Patients--A Study of Pain Rehabilitation. PLoS One 2016; 11:e0152735. [PMID: 27055029 PMCID: PMC4824419 DOI: 10.1371/journal.pone.0152735] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 01/25/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE There is a need for tools addressing gender inequality in the everyday clinical work in health care. The aim of our paper was to develop a tool for increasing the awareness of gendered and intersectional processes in clinical assessment of patients, based on a study of pain rehabilitation. METHODS In the overarching project named "Equal care in rehabilitation" we used multiple methods (both quantitative and qualitative) in five sub studies. With a novel approach we used Grounded Theory in order to synthesize the results from our sub studies, in order to develop the gender equality tool. The gender equality tool described and developed in this article is thus based on results from sub studies about the processes of assessment and selection of patients in pain rehabilitation. Inspired by some questions in earlier tools, we posed open ended questions and inductively searched for findings and concepts relating to gendered and social selection processes in pain rehabilitation, in each of our sub studies. Through this process, the actual gender equality tool was developed as 15 questions about the process of assessing and selecting patients to pain rehabilitation. As a more comprehensive way of understanding the tool, we performed a final step of the GT analyses. Here we synthesized the results of the tool into a comprehensive model with two dimensions in relation to several possible discrimination axes. RESULTS The process of assessing and selecting patients was visualized as a funnel, a top down process governed by gendered attitudes, rules and structures. We found that the clinicians judged inner and outer characteristics and status of patients in a gendered and intersectional way in the process of clinical decision-making which thus can be regarded as (potentially) biased with regard to gender, socio-economic status, ethnicity and age. IMPLICATIONS The clinical implications of our tool are that the tool can be included in the systematic routine of clinical assessment of patients for both awareness raising and as a base for avoiding gender bias in clinical decision-making. The tool could also be used in team education for health professionals as an instrument for critical reflection on gender bias. CONCLUSIONS Thus, tools for clinical assessment can be developed from empirical studies in various clinical settings. However, such a micro-level approach must be understood from a broader societal perspective including gender relations on both the macro- and the meso-level.
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Affiliation(s)
- Anne Hammarström
- Department of Public Health and Clinical Medicine, Unit of Social Medicine, Umeå University, Umeå, Sweden
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
| | - Maria Wiklund
- Department of Public Health and Clinical Medicine, Unit of Social Medicine, Umeå University, Umeå, Sweden
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Britt-Marie Stålnacke
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
| | - Arja Lehti
- Department of Clinical Sciences, Unit of Professional Development, Umeå University, Umeå, Sweden
| | - Inger Haukenes
- Department of Public Mental Health, Division of Mental Health, Norwegian Institute of Public Health, Kalfarveien 31, Bergen, Norway
- Research Unit for General Practice, Uni Research Health, Kalfarveien 31, Bergen, Norway
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Gender disparities in stress test utilization in chest pain unit patients based upon the ordering physician's gender. Crit Pathw Cardiol 2015; 13:152-5. [PMID: 25396292 DOI: 10.1097/hpc.0000000000000026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Physicians' gender may impact test utilization in the diagnosis of acute cardiovascular disease. We sought to determine if physician gender affected stress test utilization by patient gender in a low-risk chest pain observation unit. METHODS This was a retrospective consecutive cohort study of patients admitted to a chest pain unit in a large volume academic urban emergency department (ED). Inclusion criteria were age>18, American Heart Association low-to-intermediate risk, electrocardiogram nondiagnostic for acute coronary syndrome, and negative initial troponin I. Exclusion criteria were age>75 with a history of coronary artery disease, active comorbid medical problems, or inability to obtain stress testing in the ED for any reason. T-tests were used for univariate comparisons and logistic regression was used to estimate odds ratios (ORs) for receiving testing based on physician gender, controlling for race, insurance, and Thrombolysis In Myocardial Infarction (TIMI) score. RESULTS Three thousand eight hundred and seventy-three index visits were enrolled during a 2.5-year period. Mean age was 53±20, 55% (95% CI, 53-56%) were female. There was no difference in overall stress utilization based upon physician gender (P=0.28). However, after controlling for other variables, male physicians had significantly lower odds of stress testing female patients (ORM, 0.82; 95% CI, 0.68-0.99), whereas no difference was found in female physicians (ORF, 0.80; 95% CI, 0.57-1.14). CONCLUSIONS Male physicians appear less likely to utilize stress testing in female patients even after controlling for objective clinical variables, including TIMI score. Although adverse outcomes are uncommon in this patient cohort, further investigation into provider-specific practice patterns based on patient gender is necessary.
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Nilsson G, Mooe T, Söderström L, Samuelsson E. Use of exercise tests in primary care: importance for referral decisions and possible bias in the decision process; a prospective observational study. BMC FAMILY PRACTICE 2014; 15:182. [PMID: 25433410 PMCID: PMC4276015 DOI: 10.1186/s12875-014-0182-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 10/24/2014] [Indexed: 12/13/2022]
Abstract
Background The utility of clinical exercise tests depends on their support of treatment decisions. We sought to assess the utility of exercise tests for the selection of primary-care patients for referral to cardiologic care, and to determine whether referral decisions were biased by gender or socioeconomic status. We also evaluated referral rates and cardiovascular events in patients with positive exercise tests. Methods We designed a prospective observational study of 438 men and 427 women from 28 Swedish primary-care clinics who were examined with exercise testing for suspected coronary disease. All participants were followed-up with respect to cardiologist referrals and cardiovascular events (hospitalisation for unstable angina, myocardial infarction, and cardiovascular death) within six months and revascularisation within 250 days. Variables associated with referral were identified by multivariable logistic regression. Socioeconomic status was determined by educational level and employment. Results Positive/inconclusive exercise tests and exertional chest pain predicted referral in men and women. Of 865 participants, patients with positive, inconclusive, or negative exercise tests were referred to cardiologists in 67.3%, 26.1%, and 3.5% of cases, respectively. Overall, there was no significant difference in referral rates related to gender or socioeconomic level. Self-employed women were referred more frequently compared to other women (odds ratio (OR) 3.62, 95% confidence interval (CI) 1.19-10.99). Among non-manual employees, women were referred to cardiologic examination less frequently than men (OR 0.40, 95% CI 0.16-1.00; p = 0.049; ORs adjusted for age, exertional chest pain, and exercise test result). In patients with positive exercise tests, the referral rate decreased continuously with age (OR 0.48, 95% CI 0.23-0.97; adjusted for cardiovascular co-morbidity). Cardiovascular events occurred in 22.2% (4/18) of non-referred patients with positive exercise tests; 56% (10/18) of these patients were not considered for cardiologic care, with continuity problems in primary care as one possible contributing cause. Conclusions Exercise tests are important for selecting patients for referral to cardiologic care. Interactions related to gender and socioeconomic status affected referral rates. In patients with positive exercise tests, referral rates decreased with age. An increased awareness of possible bias regarding age, gender, and socioeconomic status, which may influence medical decisions, is therefore necessary. Electronic supplementary material The online version of this article (doi:10.1186/s12875-014-0182-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gunnar Nilsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden. .,Unit of Research, Education and Development, Östersund Hospital, Östersund, Sweden.
| | - Thomas Mooe
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
| | - Lars Söderström
- Unit of Research, Education and Development, Östersund Hospital, Östersund, Sweden.
| | - Eva Samuelsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
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Carretero MT, Calderón-Larrañaga A, Poblador-Plou B, Prados-Torres A. Primary health care use from the perspective of gender and morbidity burden. BMC WOMENS HEALTH 2014; 14:145. [PMID: 25433402 PMCID: PMC4258297 DOI: 10.1186/s12905-014-0145-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 11/10/2014] [Indexed: 11/10/2022]
Abstract
Background Sex and gender can interact to contribute to differences in morbidity and mortality between men and women. To detect such differences is an important issue for health policy planners when designing programmes for the provision of healthcare services for the whole population. Our aim was to study differences between men and women in the use of Primary Health Care (PHC) resources, taking into account age and morbidity burden. Methods An observational retrospective study was carried out using the information gathered in electronic medical records from 79,809 adult patients who attended a PHC centre at least once in 2008. The ACG® System was used to quantify the morbidity burden of patients. Poisson regression models were applied to analyse differences in the number of visits to the PHC centre by men and women. Results Morbidity burden was significantly higher in women of all age groups. The gross number of visits to the PHC centre was also higher for women in all age groups. However, when adjusting by age and morbidity burden, we did not find a higher utilization by women compared to men. For high levels of morbidity burden, the attendance by men was even significantly higher. Conclusions The overall higher use of PHC by women seems to be associated with their higher morbidity burden. The interaction between biology and socially constructed roles could also underlie this higher use by women, and is therefore an area that deserves further in-depth research.
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Affiliation(s)
| | - Amaia Calderón-Larrañaga
- University of Zaragoza, Zaragoza, Spain. .,EpiChron Research Group on Chronic Diseases, Aragón Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, Zaragoza, Spain. .,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Carlos III Health Institute, Madrid, Spain. .,Grupo de Investigación en Servicios Sanitarios (GRISSA), Aragón Health Sciences Institute (IACS), IIS Aragón, Zaragoza, Spain.
| | - Beatriz Poblador-Plou
- EpiChron Research Group on Chronic Diseases, Aragón Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, Zaragoza, Spain. .,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Carlos III Health Institute, Madrid, Spain. .,Grupo de Investigación en Servicios Sanitarios (GRISSA), Aragón Health Sciences Institute (IACS), IIS Aragón, Zaragoza, Spain.
| | - Alexandra Prados-Torres
- University of Zaragoza, Zaragoza, Spain. .,EpiChron Research Group on Chronic Diseases, Aragón Health Sciences Institute (IACS), IIS Aragón, Miguel Servet University Hospital, Zaragoza, Spain. .,Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Carlos III Health Institute, Madrid, Spain. .,Grupo de Investigación en Servicios Sanitarios (GRISSA), Aragón Health Sciences Institute (IACS), IIS Aragón, Zaragoza, Spain.
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Haukenes I, Hensing G, Stålnacke BM, Hammarström A. Does pain severity guide selection to multimodal pain rehabilitation across gender? Eur J Pain 2014; 19:826-33. [PMID: 25366906 DOI: 10.1002/ejp.609] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Studies have addressed the effect of multimodal pain rehabilitation (MMR), whereas criteria for selection are sparse. This study examines whether higher scores on musculoskeletal pain measures are associated with selection to MMR, and whether this differs across gender. METHOD A clinical population of 262 male and 589 female patients was recruited consecutively during 3 years, 2007-2010. The patients were referred from primary care to a pain rehabilitation clinic in Northern Sweden for assessment and selection to MMR. Register-based data on self-reported pain were linked to patients' records where outcome (MMR or not) was stated. We modelled odds ratios for selection to MMR by higher scores on validated pain measures (pain severity, interference with daily life, pain sites and localized pain vs. varying pain location). Covariates were age, educational level and multiple pain measures. Anxiety and depression (Hospital, Anxiety and Depression Scale) and working status were used in sensitivity tests. RESULTS Higher scores of self-reported pain were not associated with selection to MMR in multivariate models. Among women, higher scores on pain severity, pain sites and varying pain location (localized pain = reference) were negatively associated with selection to MMR. After adjustment for multiple pain measures, the negative odds ratio for varying location persisted (OR = 0.59, 95% CI = 0.39-0.89). CONCLUSION Higher scores on self-reported pain did not guide selection to MMR and a negative trend was found among women. Studies of referral patterns and decision processes may contribute to a better understanding of the clinical practice that decides selection to MMR.
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Affiliation(s)
- I Haukenes
- Department of Public Mental Health, Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway; Department of Public Health and Clinical Medicine, Umeå University, Sweden
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Sex differences in independent factors associated with coronary artery disease. Wien Klin Wochenschr 2014; 126:718-26. [PMID: 25216757 DOI: 10.1007/s00508-014-0602-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 08/24/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND Women undergoing coronary angiography (CA) due to chest pain are more likely to present with less extensive coronary artery disease (CAD) than men, which might be attributed to different effects of cardiovascular risk factors on coronary atherogenesis between sexes. The aim of the present study was to evaluate sex differences in independent factors associated with obstructive and non-obstructive CAD in a large consecutive cohort of patients undergoing elective CA. METHODS Data from 7819 patients (2653 women and 5184 men), including cardiovascular risk factors, clinical presentation, CAD severity and treatment decisions were analysed. RESULTS Women were older than men (65 ± 11 vs. 63 ± 11 years, p < 0.001); low-density lipoprotein cholesterol (LDL; 125 ± 38 vs. 122 ± 37 mg/dL, p < 0.001) and high-density lipoprotein cholesterol (HDL) cholesterol levels (62 ± 18 vs. 51 ± 15 mg/dL, p < 0.001) were higher in women; and smokers were more frequently men (14.4 vs. 20.1%, p < 0.001). Men more frequently had an obstructive CAD (41.1 vs. 65.6%, p < 0.001). Multivariable analyses revealed age, HDL cholesterol, hypercholesterolaemia, diabetes mellitus, arterial hypertension and a positive family history being associated with obstructive CAD in both sexes, whereas smoking was independently associated with obstructive CAD only in women. The association of hypercholesterolaemia with obstructive CAD was stronger in men. For non-obstructive CAD, no sex-specific associated factors could be identified. CONCLUSION The impact of smoking and hypercholesterolaemia on coronary atherosclerosis is different between women and men. This might be taken into account when planning individual interventions to reduce cardiovascular risk.
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Prevalencia de consumo de hipnosedantes en población ocupada y factores de estrés laboral asociados. GACETA SANITARIA 2014; 28:369-75. [DOI: 10.1016/j.gaceta.2014.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/24/2014] [Accepted: 04/11/2014] [Indexed: 11/19/2022]
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Hammarström A, Haukenes I, Fjellman Wiklund A, Lehti A, Wiklund M, Evengård B, Stålnacke BM. Low-educated women with chronic pain were less often selected to multidisciplinary rehabilitation programs. PLoS One 2014; 9:e97134. [PMID: 24849625 PMCID: PMC4029603 DOI: 10.1371/journal.pone.0097134] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 04/14/2014] [Indexed: 11/21/2022] Open
Abstract
Background There is a lack of research about a potential education-related bias in assessment of patients with chronic pain. The aim of this study was to analyze whether low-educated men and women with chronic pain were less often selected to multidisciplinary rehabilitation than those with high education. Methods The population consisted of consecutive patients (n = 595 women, 266 men) referred during a three-year period from mainly primary health care centers for a multidisciplinary team assessment at a pain rehabilitation clinic at a university hospital in Northern Sweden. Patient data were collected from the Swedish Quality Registry for Pain Rehabilitation National Pain Register. The outcome variable was being selected by the multidisciplinary team assessment to a multidisciplinary rehabilitation program. The independent variables were: sex, age, born outside Sweden, education, pain severity as well as the hospital, anxiety and depression scale (HADS). Results Low-educated women were less often selected to multidisciplinary rehabilitation programs than high-educated women (OR 0.55, CI 0.30–0.98), even after control for age, being born outside Sweden, pain intensity and HADS. No significant findings were found when comparing the results between high- and low-educated men. Conclusion Our findings can be interpreted as possible discrimination against low-educated women with chronic pain in hospital referrals to pain rehabilitation. There is a need for more gender-theoretical research emphasizing the importance of taking several power dimensions into account when analyzing possible bias in health care.
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Affiliation(s)
- Anne Hammarström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- * E-mail:
| | - Inger Haukenes
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- Division of Mental Health, Department of Public Mental Health, Norwegian Institute of Public Health, Bergen, Norway
| | - Anncristine Fjellman Wiklund
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Arja Lehti
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
| | - Maria Wiklund
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Birgitta Evengård
- Department of Clinical Microbiology, Division of Infectious Diseases, Umeå University, Umeå, Sweden
| | - Britt-Marie Stålnacke
- Umeå Centre for Gender Studies in Medicine, Umeå University, Umeå, Sweden
- Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden
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Rutledge T, Kenkre TS, Bittner V, Krantz DS, Thompson DV, Linke SE, Eastwood JA, Eteiba W, Cornell CE, Vaccarino V, Pepine CJ, Johnson BD, Bairey Merz CN. Anxiety associations with cardiac symptoms, angiographic disease severity, and healthcare utilization: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation. Int J Cardiol 2013; 168:2335-40. [PMID: 23410495 PMCID: PMC3683077 DOI: 10.1016/j.ijcard.2013.01.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 11/21/2012] [Accepted: 01/18/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anxiety is common among patients presenting with suspected coronary artery disease (CAD). In a sample of women with signs and symptoms of ischemia, we examined three anxiety markers as predictors of CAD endpoints including: 1) cardiac symptom indicators; 2) angiographic CAD severity; and 3) healthcare utilization (cardiac hospitalizations and 5-year cardiovascular [CVD] healthcare costs). METHODS Participants completed a baseline protocol including coronary angiogram, cardiac symptoms, psychosocial measures and a median 5.9-year follow-up to track hospitalizations. We calculated CVD costs based on cardiac hospitalizations, treatment visits, and CVD medications. Anxiety measures included anxiolytic medication use, Spielberger Trait Anxiety Inventory (STAI) scores, and anxiety disorder treatment history. RESULTS The sample numbered 514 women with anxiety measure data and covariates (mean age=57.5 [11.1]). One in five (20.4%) women reported using anxiolytic agents. Anxiety correlated with cardiac symptom indicators (anxiolytic use with nighttime angina and nitroglycerine use; STAI scores and anxiety disorder treatment history with nighttime angina, shortness of breath, and angina frequency). Anxiety disorder treatment history (but not STAI scores or anxiolytics) predicted less severe CAD. Anxiolytic use (but not STAI scores or anxiety disorder treatment history) predicted hospitalizations for chest pain and coronary catheterization (HRs=2.0, 95% CIs=1.1-4.7). Anxiety measures predicted higher 5-year CVD costs (+9.0-42.7%) irrespective of CAD severity. CONCLUSIONS Among women with signs and symptoms of myocardial ischemia, anxiety measures predict cardiac endpoints ranging from cardiac symptom severity to healthcare utilization. Based on these findings, anxiety may warrant greater consideration among women with suspected CAD.
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Affiliation(s)
- Thomas Rutledge
- VA San Diego Healthcare System, San Diego, CA, United States; University of California, San Diego, CA, United States.
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Handberg EM, Eastwood JA, Eteiba W, Johnson BD, Krantz DS, Thompson DV, Vaccarino V, Bittner V, Sopko G, Pepine CJ, Merz NB, Rutledge TR. Clinical implications of the Women's Ischemia Syndrome Evaluation: inter-relationships between symptoms, psychosocial factors and cardiovascular outcomes. WOMEN'S HEALTH (LONDON, ENGLAND) 2013; 9:479-90. [PMID: 24007253 PMCID: PMC4136496 DOI: 10.2217/whe.13.50] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Cardiovascular disease remains the leading cause of death in the USA and is associated with several modifiable (hypertension, diabetes, high cholesterol, tobacco use, physical inactivity, obesity and unhealthy diet) and nonmodifiable (age, gender and family history) risk factors. The role of psychosocial risk factors in the development of cardiovascular disease has a growing body of literature, and differences in men and women have been identified. The Women's Ischemia Syndrome Evaluation provides insight into psychosocial risk factors in a cohort of women presenting with chest pain who had a comprehensive battery of psychosocial assessments and long-term follow-up. This review focuses on symptom presentation for chest pain and its relationship to cardiovascular disease morbidity and mortality, quality of life, healthcare costs and psychosocial predictor variables, including anxiety, depression, hostility and social networks. In the Women's Ischemia Syndrome Evaluation, persistent chest pain was associated with an increased rate of adverse events and relatively high rates of depression and anxiety, with reduced functional capacity and impaired quality of life, over a median of 6 years of follow-up. More research is needed to better understand the relationships between symptoms and negative emotions and to determine whether psychological (pharmacologic and/or cognitive) interventions might impact both psychological and cardiovascular outcomes.
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Affiliation(s)
- Eileen M Handberg
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA.
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Ronga A, Vaucher P, Haasenritter J, Donner-Banzhoff N, Bösner S, Verdon F, Bischoff T, Burnand B, Favrat B, Herzig L. Development and validation of a clinical prediction rule for chest wall syndrome in primary care. BMC FAMILY PRACTICE 2012; 13:74. [PMID: 22866824 PMCID: PMC3444903 DOI: 10.1186/1471-2296-13-74] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 07/16/2012] [Indexed: 11/10/2022]
Abstract
Background Chest wall syndrome (CWS), the main cause of chest pain in primary care practice,
is most often an exclusion diagnosis. We developed and evaluated a clinical
prediction rule for CWS. Methods Data from a multicenter clinical cohort of consecutive primary care patients with
chest pain were used (59 general practitioners, 672 patients). A final diagnosis
was determined after 12 months of follow-up. We used the literature and bivariate
analyses to identify candidate predictors, and multivariate logistic regression
was used to develop a clinical prediction rule for CWS. We used data from a German
cohort (n = 1212) for external validation. Results From bivariate analyses, we identified six variables characterizing CWS: thoracic
pain (neither retrosternal nor oppressive), stabbing, well localized pain, no
history of coronary heart disease, absence of general practitioner’s
concern, and pain reproducible by palpation. This last variable accounted for 2
points in the clinical prediction rule, the others for 1 point each; the total
score ranged from 0 to 7 points. The area under the receiver operating
characteristic (ROC) curve was 0.80 (95% confidence interval 0.76-0.83) in the
derivation cohort (specificity: 89%; sensitivity: 45%; cut-off set at 6 points).
Among all patients presenting CWS (n = 284), 71% (n = 201)
had a pain reproducible by palpation and 45% (n = 127) were correctly
diagnosed. For a subset (n = 43) of these correctly classified CWS
patients, 65 additional investigations (30 electrocardiograms, 16 thoracic
radiographies, 10 laboratory tests, eight specialist referrals, one thoracic
computed tomography) had been performed to achieve diagnosis. False positives
(n = 41) included three patients with stable angina (1.8% of all
positives). External validation revealed the ROC curve to be 0.76 (95% confidence
interval 0.73-0.79) with a sensitivity of 22% and a specificity of 93%. Conclusions This CWS score offers a useful complement to the usual CWS exclusion diagnosing
process. Indeed, for the 127 patients presenting CWS and correctly classified by
our clinical prediction rule, 65 additional tests and exams could have been
avoided. However, the reproduction of chest pain by palpation, the most important
characteristic to diagnose CWS, is not pathognomonic.
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Affiliation(s)
- Alexandre Ronga
- Institute of General Medicine, University of Lausanne, Lausanne, Switzerland.
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Byrsell F, Regnell M, Johansson A. Adherence to treatment guidelines for patients with chest pain varies in a nurse-led prehospital ambulance system. Int Emerg Nurs 2012; 20:162-6. [PMID: 22726948 DOI: 10.1016/j.ienj.2011.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Revised: 08/09/2011] [Accepted: 08/13/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Fredrik Byrsell
- Department of Health Sciences, Lund, Faculty of Medicine, Lund University, PO Box 157, SE-221 00 Lund, Sweden
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