[Proposing a workload indicator for hospital at home patients in Osakidetza - Basque Public Health Service]

INTRODUCTION AND OBJECTIVES

The Hospital at Home (HaH) setting currently lacks adequate workload indicators. This study suggests an indicator that can help in improving professional resources allocation.

MATERIALS AND METHODS

Prospective data was collected during May 2021 from patients treated in nine HaH units of Osakidetza-Basque Health Service (North of Spain). Direct care and travel times of healthcare staff was recorded. Data on inpatient days, number of visits, sociodemographic variables, health status, and patient pathologies, among others, were collected. The proposed indicator encompasses both the average visit time and the visit rates. It is called intensity and represents the average daily workload time per patient.

RESULTS

A total of n = 1,171 users were included in the analyses. Their mean age was 69.8 years, 45.5% were women and 25% lived more than 12 km away from the corresponding HaH unit. Workload variations were observed for nursing-only and medical-nursing teams, depending on the type of day and patient classification group. The average nursing-only teams workload time on working days was 10.82 min and on non-working days it was 14.78 min. The average workload time for medical-nursing teams, during the same days, was 20.40 min and 4.59 min, respectively. It was observed that certain patient types, like those in palliative care, represented a high workload for medical-nursing teams on working days.

CONCLUSIONS

The intensity indicator can help answering the question of how many patients can be assigned to a professional. It can also be used to adjust the staffing needs of the HaH units.

[Factors associated with the hospital at home workload: A Delphi consensus study]

OBJECTIVES

To identify and prioritize a list of factors that contribute to the workload of the hospital at home (HaH) professionals.

MATERIAL AND METHODS

A qualitative methodology study performed between January and December 2019 in the 10 HAH units of the Basque Country. The data were obtained in 4phases: 1. Systematic literature search and review; 2. Expert group meeting; 3. Consensus method: Delphi technique (2 survey rounds) and nominal group meeting; 4. Meeting of the research team.

RESULTS

In the systematic literature search and review 85 factors were initially identified. These were reduced to 38 after the 8-person expert group meeting, in which 10 new factors were added. After the 2 Delphi rounds (106 and 57 professionals, respectively), 17 factors were maintained and 12 remained in doubt. The latter were evaluated at the nominal group meeting, consisting of 13 professionals who decided to eliminate 5 factors, include 3, and keep 3 as doubt. After the 8-person research team meeting, 14 potential factors were finally selected. They are related to the place of residence, the health state and social situation of the patients, as well as the health care provided at home.

CONCLUSIONS

The identified factors could serve for improving the organization and optimize the daily word of the HaH professionals.

[Evaluation of the collaboration between Primary and Hospital Care in order to improve inappropriate prescription]

INTRODUCTION AND OBJECTIVES

To evaluate the implementation of a collaborative experience between Primary (PC) and Hospital Care (HC) aimed at reducing potentially inappropriate prescribing (PIP) in patients with polypharmacy.

MATERIALS AND METHODS

Collaborative experience including a controlled before-after intervention study, carried out in the Donostialdea Integrated Health Organization (IHO), with Bilbao Basurto IHO as control group, Osakidetza, Basque Health Service. Participant were 227 PC physicians and physicians from 7 hospital services, and patients with 5 or more drugs meeting at least one PIP criteria. The intervention consisted of communication and knowledge between professionals, PC-HC consensus, training, identification of patients at risk, medication review, evaluation and feed-back. The collaboration process (agreements, consensus documents, training activities) and the change in the prevalence of PIP in polymedicated patients (using computerised health records) were evaluated.

RESULTS

A total of 21 PIP criteria and 6 recommendation documents were agreed. An analysis was performed on 15,570 PIP from OSI Donostialdea and 24,866 from the control group. The prevalence of PIP in polymedicated patients was reduced by -4.53% (95% CI: -4.71 to -4.36, P< .0001) in comparison with the control group. The before-after differences were statistically significant across the 7 services.

CONCLUSIONS

PC-HC collaboration is feasible and, along with other intervention components, reduces inappropriate polypharmacy in the context of a recently integrated healthcare organisation. The collaboration process is complex and requires continuous monitoring, policy involvement, leadership that encourages health professional participation, and intensive use of information systems.

HEALTH STATUS AND LIFESTYLE HABITS OF VULNERABLE, COMMUNITY-DWELLING OLDER PEOPLE DURING THE COVID-19 LOCKDOWN

This study evaluated the health status and lifestyle habits of vulnerable, community-dwelling older adults during the first COVID-19 lockdown in Spain. A telephone assessment was carried out in 38 individuals (71% women), with a Barthel index ≥85 who were frail or had a high risk of falls. Data were compared with those from an assessment performed 9 months earlier. In the latter part of the lockdown, a high percentage of the studied individuals showed difficulties in walking up 10 steps and reported sleep problems (66%) and pain (74%). On the other hand, participants were not anxious/depressed (71%) and the majority did not report loneliness (60%). Compared to the earlier assessment, we identified a decline in functional capacity and worsening of nutritional status, but an increase in family support. Efforts should be made to implement intervention programs seeking to avoid accelerated decline under the current pandemic situation, and especially during possible new lockdowns.

Treatment of ano-genital warts: the effect of an educational event on practitioner choice

To determine whether an educational event can affect treatment choice for ano-genital warts, genitourinary medicine clinicians attending a wart management lecture were shown 14 photographs of genital warts of differing morphology at different sites and asked to choose their preferred method of treatment. Study questionnaires were completed pre-lecture and repeated after the lecture and discussion. Podophyllin was chosen significantly less frequently and cryotherapy more frequently post-lecture for certain wart types. Podophyllotoxin was favoured for multiple small penile and posterior fourchette warts, whereas imiquimod was chosen predominantly for large or bulky lesions. Trichloracetic acid was infrequently chosen as a treatment option (<6% of respondents). This study has shown that clinicians attending a lecture on the management of ano-genital warts do change their treatment choice for certain clinical scenarios. Whether opting for a particular treatment in a lecture setting translates to altered practice in the clinical setting requires further study.

[Cross-cultural adaptation into Spanish of the Nursing Home Survey on Patient Safety Culture questionnaire]

OBJECTIVE

This article presents the first phase of a research project aimed at adapting a tool for assessing safety culture in nursing homes into Spanish.

MATERIAL AND METHODS

The Nursing Home on Patient Safety Culture of the Agency for Health Care Research and Quality was translated and culturally adapted. The International Quality of Life Assessment protocol was followed, which included, translation, conceptual equivalence evaluation, back-translation, content validity and a pilot study.

RESULTS

Three of the 42 items were modified with respect to the original version. The remaining modifications were introduced in the F Section, containing sociodemographic information and job related questions.

CONCLUSIONS

The adapted questionnaire will help to assess the level of safety of the resident culture among healthcare professionals in these centres, to identity areas for improvement, and to analyze how to evolve when organizational changes are introduced.

Patient acceptable symptom state and OMERACT-OARSI set of responder criteria in joint replacement. Identification of cut-off values

OBJECTIVE

To identify new cut-off values beyond which patients can be considered as satisfied or as responders through patient acceptable symptom state (PASS) and OMERACT-OARSI (Outcome Measures in Rheumatology-Osteoarthritis Research Society International) set of responder criteria in total joint replacement.

METHODS

Secondary analysis of a 1-year prospective multicenter study of 861 patients, 510 with total knee replacement (TKR) and 351 with total hip prosthesis (THR). Pain and function data were collected by the reverse scoring option of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). PASS values were identified with the 25th centile estimation using an anchoring question about satisfaction with actual symptoms. OMERACT-OARSI set of responder criteria was based on a combination of absolute and relative change of pain, function and global patient's assessment. Receiver operating characteristic (ROC) analysis was used as a complementary approach.

RESULTS

The values for PASS were about 80 and 69 for pain and function in THR, while these values were 80 and 68 when using OMERACT-OARSI criteria. Regarding TKR, PASS values were about 75 and 67 in pain and function with both criteria. ROC values were slightly lower in all cases. PASS and OMERACT-OARSI values varied moderately across tertiles of baseline severity.

CONCLUSION

With the provided data we can establish when a patient can be considered as satisfied/responder in joint replacement. The scores achieved at 1 year were very similar according to both criteria.

The timing of calcium measurements in helping to predict temporary and permanent hypocalcaemia in patients having completion and total thyroidectomies

INTRODUCTION

Postoperative hypocalaemia commonly occurs after extensive thyroid surgery and may require calcium and/or vitamin D supplements to alleviate or prevent the symptoms. In this study, we determined the risk factors for developing hypocalcaemia and whether early serum calcium levels can predict the development of or differentiate between temporary or permanent hypocalcaemia.

PATIENTS AND METHODS

A total of 162 patients who either had a completion or total thyroidectomy formed the basis of this prospective study. Serial serum calcium measurements were recorded as well as details of the operation, pathology, indications for surgery, number of parathyroids identified at operation and any complications.

RESULTS

Eighty-four (52%) patients did not develop hypocalcaemia but 69 (43%) were found to have temporary hypocalcaemia and 9 (5%) had permanent hypocalcaemia. Hypocalcaemia was more common after total than completion thyroidectomies and the identification of parathyroids at operation appears to have a significant adverse effect on outcome. The calcium levels measured on day 1 postoperatively and the slope (serum calcium levels of day 1 postoperative minus day of operation) were statistically significant in predicting the development of hypocalcaemia and possibly to differentiate between temporary or permanent hypocalcaemia.

DISCUSSION

Although almost half the patients having extensive thyroid surgery developed hypocalcaemia (as defined by any postoperative corrected serum calcium level of < 2.12 mmol/l) only 24% had a serum calcium of < 2.12 mmol/l associated with clinical symptoms of hypocalcaemia or a calcium level of < 2.0 mmol/l. Only 5% had persistent hypocalcaemia defined as requiring exogenous supplements at 6 months' postoperatively. Patients having a completion thyroidectomy appear to be less likely to develop hypocalcaemia perhaps as a result of any iatrogenic effects on the parathyroids at the first operation being reversed before the second operation. Identification and, therefore, exposure of parathyroids at operation may have an adverse effect on the blood supply to the glands affecting their function.

CONCLUSIONS

Serum calcium levels measured 6 hours' post-surgery and on day 1 postoperatively can be useful in predicting if the patient will develop hypocalcaemia and the slope may indicate whether the hypocalcaemia will be temporary or permanent. Patients with toxic goitres and those having a one-stage total thyroidectomy are most at risk of developing hypocalcaemia.

Modafinil for the treatment of fatigue in lung cancer: a pilot study

Cancer-related fatigue is the most prevalent and distressing symptom experienced by patients with advanced cancer. Central nervous system stimulants have been shown to relieve fatigue in nonmalignant disease. Modafinil is a stimulant with a selective site of action in the brain that is better tolerated than traditional stimulants, such as methylphenidate. The aim of this study was to determine the feasibility of conducting a randomised controlled trial to assess the efficacy and safety of modafinil for the treatment of fatigue in patients with lung cancer. Twenty patients with non-small cell lung cancer were recruited to this open-label study. Modafinil was taken in a fixed dose-titration schedule of 100 mg daily for 7 days followed by 200 mg daily for 7 days. Fifteen patients completed the study. During the study period, there was a rapid and statistically significant reduction in the primary outcome, fatigue (P = 0.001) and the secondary outcomes of daytime sleepiness and depression/anxiety. This improvement in fatigue was also clinically significant. Ten patients chose to continue modafinil after the study and the drug was well-tolerated. It would be both feasible and worthwhile to conduct a definitive randomised controlled trial to determine the role of modafinil in the treatment of cancer-related fatigue.

Vision screening in children by Plusoptix Vision Screener compared with gold-standard orthoptic assessment

BACKGROUND/AIMS

To evaluate a new autorefractor, the Plusoptix Vision Screener (PVS), as a screening tool to detect risk factors for amblyopia by comparing it with gold-standard orthoptic vision screening in children.

METHODS

Community-based screening study including 288 children age 4-7 years who were screened with the PVS and by orthoptic assessment (distance acuity, cover test, extraocular movements, 20 PD prism test, Lang stereotest). Follow-up comprehensive eye examination of screening-positive children included manual cycloplegic retinoscopy.

RESULTS

Testability was high for both methods. Orthoptic screening identified 36 children with reduced vision and/or factors associated with amblyopia (referral rate 12.5%). The PVS identified 16 children with potential vision problems (referral rate 5.6%), indicating only moderate sensitivity (44%; 95% CI 27.9 to 61.9%), but high specificity (100%; 95% CI 98.5 to 100%) to detect factors associated with amblyopia. The PVS underestimated visually significant refractive errors.

CONCLUSIONS

Use of the PVS as single screening test in young children may miss a significant number of children with amblyopia or amblyogenic risk factors.

Plusoptix Vision Screener: the accuracy and repeatability of refractive measurements using a new autorefractor

BACKGROUND

The Plusoptix Vision Screener (PVS) is a new non-cycloplegic videoretinoscopy autorefractor. Refractive accuracy may affect its performance as a screening tool.

AIMS

Study 1: To determine the intra- and interobserver variability of PVS measurements. Study 2: To compare PVS measurements with gold-standard manual cycloplegic retinoscopy (MCR).

METHODS

Study 1: PVS refraction of 103 children with mean (SD) age 5.5 (0.6) years by two observers. Study 2: PVS and MCR refraction of 126 children with mean (SD) age 5.5 (1.5) years, including 43 children with manifest strabismus >/=5 PD, comparing mean spherical equivalent (MSE) and Jackson cross cylinders J(0) and J(45).

RESULTS

Study 1: Repeatability coefficients (observer 1): MSE: 0.63 D, J(0): 0.24 D, J(45): 0.18 D; those of observer 2 were nearly identical. The mean difference (95% limits of agreement) between the two observers for MSE, J(0) and J(45) were, respectively, 0.03 (-0.62 to 0.68 D), -0.008 (-0.25 to 0.23 D) and 0.013 (-0.18 to 0.20) D. Study 2: MSE tended to be lower on PVS than MCR, with differences of up to 8.00 D. Less than 20% of values were within +/-0.50 D of each other. Agreement was better for J(0) and J(45). Strabismus was associated with an odds ratio of 3.7 (95% CI 1.3 to 10.5) of the PVS failing to obtain a reading.

CONCLUSIONS

The PVS may underestimate children's refractive error.

South Asian women with polycystic ovary syndrome exhibit greater sensitivity to gonadotropin stimulation with reduced fertilization and ongoing pregnancy rates than their Caucasian counterparts

Polycystic ovary syndrome (PCOS) is a heterogeneous syndrome. In vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) is required for PCOS cases that are refractory to standard ovulation induction or have co-existing infertility factors in women with PCOS and Tubal factor subfertility.

OBJECTIVES

Assess ethnic variations in response to IVF/ICSI treatment.

STUDY DESIGN

Observational Comparative study in a University hospital fertility clinic in women with PCOS and Tubal factor subfertility. Women with PCOS (Asians: AP=104; Caucasians: CP=220) and those with tubal factor infertility seeking fertility treatment were assessed (Asians: AC=84; Caucasians: CC=200). Six hundred and eight fresh IVF or ICSI cycles using long protocol of GnRHa suppression and resulting in a fresh embryo transfer were compared. The primary endpoint was to assess the dose of gonadotropins used in the cycles. The secondary outcomes were: total number of oocytes retrieved, fertilization and ongoing clinical pregnancy rates.

RESULTS

We found that the South Asian women presented at a younger age for the management of sub-fertility. An extended stimulation phase and Caucasian ethnicity showed an inverse correlation with the number of oocytes retrieved in the PCOS subgroup. Caucasian ethnicity was associated with a higher fertilization rate however increase in body mass index (BMI) and the laboratory technique of IVF appeared to have a negative impact on fertilization rates in the PCOS subgroup. Commencing down regulation on day 1 of the cycles was negatively associated with fertilization rates in the tubal group. In terms of clinical pregnancy rates, the Caucasian PCOS had a 2.5 times (95% CI: 1.25-5) higher chance of an ongoing clinical pregnancy as compared with their Asian counterpart. Also, a unit increase in the basal FSH concentration reduced the odds of pregnancy by 18.6% (95% CI: 1.8-32.6%) in the PCOS group.

CONCLUSIONS

The Asian PCOS have a greater sensitivity to gonadotropin stimulation with lower fertilization and ongoing clinical pregnancy rates as compared with their Caucasian counterparts.