Continuing to Confront COPD International Physician Survey: Physician Knowledge and Application of COPD Management Guidelines in 12 Countries

AIM: Utilizing data from the Continuing to Confront COPD (chronic obstructive pulmonary disease) International Physician Survey, this study aimed to describe physicians\u27 knowledge and application of the GOLD (Global initiative for chronic Obstructive Lung Disease) Global Strategy for the Diagnosis, Management and Prevention of COPD diagnosis and treatment recommendations and compare performance between primary care physicians (PCPs) and respiratory specialists. MATERIALS AND METHODS: Physicians from 12 countries were sampled from in-country professional databases; 1,307 physicians (PCP to respiratory specialist ratio three to one) who regularly consult with COPD, emphysema, or chronic bronchitis patients were interviewed online, by telephone or face to face. Physicians were questioned about COPD risk factors, prognosis, diagnosis, and treatment, including knowledge and application of the GOLD global strategy using patient scenarios. RESULTS:Physicians reported using spirometry routinely (PCPs 82%, respiratory specialists 100%; P\u3c0.001) to diagnose COPD and frequently included validated patient-reported outcome measures (PCPs 67%, respiratory specialists 81%; P\u3c0.001). Respiratory specialists were more likely than PCPs to report awareness of the GOLD global strategy (93% versus 58%, P\u3c0.001); however, when presented with patient scenarios, they did not always perform better than PCPs with regard to recommending GOLD-concordant treatment options. The proportion of PCPs and respiratory specialists providing first- or second-choice treatment options concordant with GOLD strategy for a GOLD B-type patient was 38% versus 67%, respectively. For GOLD C and D-type patients, the concordant proportions for PCPs and respiratory specialists were 40% versus 38%, and 57% versus 58%, respectively. CONCLUSION: This survey of physicians in 12 countries practicing in the primary care and respiratory specialty settings showed high awareness of COPD-management guidelines. Frequent use of guideline-recommended COPD diagnostic practices was reported; however, gaps in the application of COPD-treatment recommendations were observed, warranting further evaluation to understand potential barriers to adopt guideline recommendations

The attitudes, knowledge and practices of Maltese family doctors in disease prevention and health promotion

Introduction: Family doctors are in a unique position to advocate health promotion and disease prevention, though it is known that this is not always given its due importance due to various reasons. Aim: To assess the knowledge, attitudes and practices of Maltese family doctors in health promotion and disease prevention. The results of the study were compared with a similar study in 2000. Methodology: A validated questionnaire was sent in 2011 to all Maltese general practitioners (GPs) and GP trainees. The results were analysed statistically. A focus group was conducted to discuss the results and develop a set of recommendations. Results: An improvement was seen in health promotion practice since 2000. Family doctors look after their own health better. However, they have difficulties regarding which prevention guidelines they should follow. Time constraints remain the biggest obstacle to promoting health. GPs who are involved in post- graduate teaching activities find it easier to promote health (p<0.05), while doctors working in both private and public settings find it most difficult (p<0.05). GPs who smoke find it harder to advise on smoking cessation (p<0.05), while doctors who are obese find it more difficult to recommend exercise (p<0.05). Conclusions and recommendations: Health promotion practice by family doctors is on the increase, yet there is clearly room for enhancement of their service. Web-based training, lectures and seminars would help family doctors to enhance their knowledge. Flyers, posters and video-clips in waiting areas could increase patient awareness on healthy lifestyles.peer-reviewe

Integrated control of chagas disease for its elimination as public health problem: A review

Chagas disease or American trypanosomiasis is, together with geohelminths, the neglected disease that causes more loss of years of healthy life due to disability in Latin America. Chagas disease, as determined by the factors and determinants, shows that different contexts require different actions, preventing new cases or reducing the burden of disease. Control strategies must combine two general courses of action including prevention of transmission to prevent the occurrence of new cases (these measures are cost effective), as well as opportune diagnosis and treatment of infected individuals in order to prevent the clinical evolution of the disease and to allow them to recuperate their health. All actions should be implemented as fully as possible and with an integrated way, to maximise the impact. Chagas disease cannot be eradicated due because of the demonstrated existence of infected wild triatomines in permanent contact with domestic cycles and it contributes to the occurrence of at least few new cases. However, it is possible to interrupt the transmission of Trypanosoma cruzi in a large territory and to eliminate Chagas disease as a public health problem with a dramatic reduction of burden of the disease.Fil: Sosa-Estani, Sergio Alejandro. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Segura, Elsa Leonor. Dirección Nacional de Instituto de Investigación. Administración Nacional de Laboratorio e Instituto de Salud. Instituto Nacional de Parasitología; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Projections of the healthcare costs and disease burden due to hepatitis C infection under different treatment policies in Malaysia, 2018-2040

The World Health Organisation (WHO) has set ambitious goals to reduce the global disease burden associated with, and eventually eliminate, viral hepatitis

General practice

The remarkable rate of development of medical knowledge and pharmacology affects all medical specialties and in particular general practice, since the latter embraces various aspects of different medical fields. Certain areas of medical practice, such as Hormone Replacement Therapy (HRT), hypercholesterolaemia and drugs affecting the Renin Angiotensin System (RAS) feature in a vast amount of literature which is constantly being updated. The increasing awareness of the previously unknown effects of HRT on one side, and the widespread prevalence of cardiovascular disease in the case of hypercholesterolaemia and drugs affecting the RAS have contributed to this large amount of studies. On the other hand, certain areas of practice such as atopic eczema and anti-thrombotic therapy have been rather quiescent as far as developments are concerned, but revolutionary treatments have recently been introduced in both areas, namely the calcineurin antagonists and ximelagratan. The latter is a very promising drug which can replace warfarin, while the former are the first steroid-sparing medications which effectively control atopic eczema. Keeping abreast with recent developments is a further hurdle which the modern general practioner has to contend with in order to offer valid treatment options, and to be able to answer questions by increasingly well-informed patients.peer-reviewe

Telemonitoring after discharge from hospital with heart failure: cost-effectiveness modelling of alternative service designs.

Objectives To estimate the cost-effectiveness of remote monitoring strategies versus usual care for adults recently discharged after a heart failure (HF) exacerbation. Design Decision analysis modelling of cost-effectiveness using secondary data sources. Setting Acute hospitals in the UK. Patients Patients recently discharged (within 28 days) after a HF exacerbation. Interventions Structured telephone support (STS) via human to machine (STS HM) interface, (2) STS via human to human (STS HH) contact and (3) home telemonitoring (TM), compared with (4) usual care. Main outcome measures The incremental cost per quality-adjusted life year (QALY) gained by each strategy compared to the next most effective alternative and the probability of each strategy being cost-effective at varying willingness to pay per QALY gained. Results TM was the most cost-effective strategy in the scenario using these base case costs. Compared with usual care, TM had an estimated incremental cost effectiveness ratio (ICER) of £11 873/QALY, whereas STS HH had an ICER of £228 035/QALY against TM. STS HM was dominated by usual care. Threshold analysis suggested that the monthly cost of TM has to be higher than £390 to have an ICER greater than £20 000/QALY against STS HH. Scenario analyses performed using higher costs of usual care, higher costs of STS HH and lower costs of TM do not substantially change the conclusions. Conclusions Cost-effectiveness analyses suggest that TM was an optimal strategy in most scenarios, but there is considerable uncertainty in relation to clear descriptions of the interventions and robust estimation of costs

Trauma and acute care surgeons report prescribing less opioids over time.

IntroductionConfronted with the opioid epidemic, surgeons must play a larger role to reduce risk of opioid abuse while managing acute pain. Having a better understanding of the beliefs and practices of trauma and acute care surgeons regarding discharge pain management may offer potential targets for interventions beyond fixed legal mandates.MethodsAn Institutional Review Board-approved electronic survey was sent to trauma and acute care surgeons who are members of the American Association for the Surgery of Trauma, and trauma and acute care surgeons and nurse practitioners at a Level 1 trauma center in February 2018. The survey included four case-based scenarios and questions about discharge prescription practices and beliefs.ResultsOf 66 respondents, most (88.1%) were at academic institutions. Mean number of opioid tablets prescribed was 20-30 (range 5-90), with the fewest tablets prescribed for elective laparoscopic cholecystectomy and the most for rib fractures. Few prescribed both opioid and non-opioid medications (22.4% to 31.4 %). Most would not change the number/strength of medications (69.2%), dose (53.9%), or number of tablets of opioids (83.1%) prescribed if patients used opioids regularly prior to their operation. The most common factors that made providers more likely to prescribe opioids were high inpatient opioid use (32.4%), history of opioid use/abuse (24.5%), and if the patient lives far from the hospital (12.9%). Most providers in practice &gt;5 years reported a decrease in opioids (71.9%) prescribed at discharge.ConclusionTrauma and acute care surgeons and nurse practitioners reported decreasing the number/amount of opioids prescribed over time. Patients with high opioid use in the hospital, history of opioid use/abuse, or who live far from the provider may be prescribed more opioids at discharge.Level of evidenceLevel IV

Task shifting and integration of HIV care into primary care in South Africa: The development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention

Background: Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial. Methods: Developing the intervention: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services. Results: Components of the intervention: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process. Discussion: Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout