Standard of care: how can we safeguard it?

published_or_final_versio

Simple non-laboratory-based and laboratory-based risk assessment algorithms and nomogram for detecting undiagnosed diabetes mellitus

This journal suppl. entitled: Abstracts of the 10th International Diabetes Federation–Western Pacific Region Congress and the 6th AASD Scientific MeetingBACKGROUND: Early detection for undiagnosed diabetes mellitus (DM), through routine screening periodically, is critical to prevent or delay severe diabetes-related complications. In order to classify high-risk subjects for DM screening, risk algorithms for undiagnosed DM detection have been richly developed and validated in diverse populations and health care settings. However, the majority of risk algorithms developed within Chinese population were developed and validated in low income setting. Furthermore, there are no nomograms for the use in detecting undiagnosed DM, of which are simple-to-use graphical tool to guide decision-making in both routine clinical practice and community setting. The purpose of this study was to develop simple a nomogram to predict the risk of undiagnosed DM for use in asymptomatic general population, based on non-laboratory-based ...postprin

Using illness scripts to teach clinical reasoning skills to medical students

Background and Objectives: Most medical students learn clinical reasoning skills informally during clinical rotations that have varying quality of supervision. We conducted a randomized controlled trial to determine if a workshop that uses "illness scripts" could improve students' clinical reasoning skills when making diagnoses of patients portrayed in written scenarios. Methods: In 2007-2008, 53 fourth-year medical students were randomly assigned to either a family medicine (intervention) or psychiatry (control) clerkship at The Chinese University of Hong Kong. Students in the intervention group participated in a 3-hour workshop on clinical reasoning that used illness scripts. The workshop was conducted with small-group teaching using a Web-based set of clinical reasoning problems, individualized feedback, and demonstration of tutors' reasoning aloud. The effectiveness of the intervention was assessed using the Diagnostic Thinking Inventory (DTI) and the measurement of individual students' performance in solving clinical reasoning problems (CRP). Results: The postintervention overall DTI scores between groups were similar (mean difference 0, 95% confidence interval [CI]= -7.4 to 7.4). However, the total scores on the CRP assessment were 14% (95% CI=8% to 21%) higher in the intervention group than in controls. Conclusion: A workshop on illness scripts may have some benefit for improving diagnostic performance in clinical reasoning problems.link_to_OA_fulltex

Simple Non-laboratory- and Laboratory-based Risk Assessment Algorithms and Nomogram for Detecting Undiagnosed Diabetes Mellitus

Background: To develop a simple nomogram which can be used to predict the risk of diabetes mellitus (DM) in asymptomatic non-diabetic general population based on non-laboratory-based and laboratory-based risk algorithms. Methods: Anthropometric data, plasma fasting glucose, full lipid profile, exercise habit and family history of DM were collected from Chinese non-diabetic subjects aged 18-70. Logistic regression analysis was performed on the data of a random sample of 2518 subjects to construct non-laboratory-based and laboratory-based risk assessment algorithms for the detection of undiagnosed DM; both algorithms were validated on the data of the remaining sample (n=839). Hosmer-Lemeshow χ2 statistic and area under the receiver-operating characteristic curve (AUC) were employed to assess the calibration and discrimination of the different DM risk algorithms. Results: Of 3357 subjects recruited, 271 (8.1%) had undiagnosed DM defined by fasting glucose≥7.0mmol/L or 2-hour post-load plasma glucose≥11.1mmol/L after oral glucose tolerance test. The non-laboratory-based risk algorithm, with score ranging from 0 to 33, included age, body mass index, family history of DM, regular exercise and uncontrolled blood pressure; the laboratory-based risk algorithm, with score ranging from 0 to 37, added triglyceride level to the risk factors. Both algorithms demonstrated acceptable calibration (Hosmer-Lemeshow test: P=0.229 and P=0.483, respectively) and discrimination (AUC: 0.709 and 0.711, respectively) for the detection of undiagnosed DM. The optimal cutoff point on the receiver-operating characteristic curve was 18 for the detection of undiagnosed DM in both algorithms. Conclusions: Simple-to-use nomogram for detecting undiagnosed DM has been developed using the validated non-laboratory-based and laboratory-based risk algorithms.postprin

Evaluation of quality of care of Chronic Disease Management Programmes and Public-Private Partnership Programmes of the Hospital Authority

Parallel Session 3 – Delivery of Health Services: no. S12Conference Theme: Translating Health Research into Policy and Practice for Health of the Populationpublished_or_final_versio

A qualitative study of the views of patients with long-term conditions on family doctors in Hong Kong

<b>Background</b> Primary care based management of long-term conditions (LTCs) is high on the international healthcare agenda, including the Asia-Pacific region. Hong Kong has a 'mixed economy' healthcare system with both public and private sectors with a range of types of primary care doctors. Recent Hong Kong Government policy aims to enhance the management of LTCs in primary care possibly based on a 'family doctor' model. Patients' views on this are not well documented and the aim of the present study was to explore the views of patients with LTCs on family doctors in Hong Kong.<p></p> <b>Methods</b> The views of patients (with a variety of LTCs) on family doctors in Hong Kong were explored. Two groups of participants were interviewed; a) those who considered themselves as having a family doctor, b) those who considered themselves as not having a family doctor (either with a regular primary care doctor but not a family doctor or with no regular primary care doctor). In-depth individual semi-structured interviews were carried out with 28 participants (10 with a family doctor, 10 with a regular doctor, and 8 with no regular doctor) and analysed using the constant comparative method.<p></p> <b>Results</b> Participants who did not have a family doctor were familiar with the concept but regarded it as a 'luxury item' for the rich within the private healthcare system. Those with a regular family doctor (all private) regarded having one as important to their and their family's health. Participants in both groups felt that as well as the more usual family medicine specialist or general practitioner, traditional Chinese medicine practitioners also had the potential to be family doctors. However most participants attended the public healthcare system for management of their LTCs whether they had a family doctor or not. Cost, perceived need, quality, trust, and choice were all barriers to the use of family doctors for the management of their LTCs.<p></p> <b>Conclusions</b> Important barriers to the adoption of a 'family doctor' model of management of LTCs exist in Hong Kong. Effective policy implementation seems unlikely unless these complex barriers are addressed

Assessing the Consultation and Relational Empathy (CARE) Measure in sexual health nurses' consultations

Background: Increasingly healthcare policies emphasise the importance of person-centred, empathic care. Consequently, healthcare professionals are expected to demonstrate the ‘human’ aspects of care in training and in practice. The Consultation and Relational Empathy (CARE) Measure is a patient-rated measure of the interpersonal skills of healthcare practitioners. It has been widely validated for use by healthcare professionals in both primary and secondary care. This paper reports on the validity and reliability of the CARE Measure with sexual health nurses. Methods: Patient questionnaires were collected for 943 consultations with 20 sexual health nurses. Participating patients self-completed the questionnaire immediately after the encounter with the nurse. The questionnaire included the ten item CARE Measure, the Patient Enablement Index, and overall satisfaction instruments. Construct validity was assessed through Spearman’s correlation and principal component analysis. Internal consistence was assessed through Cronbach’s alpha and the inter-rater reliability through Generalisability Theory. Data were collected in 2013 in Scotland. Results: Female patients completed 68% of the questionnaires. The mean patient age was 28.8 years (standard deviation 9.8 years). Two of the 20 participating nurses withdrew from the study. Most patients (71.7%) regarded the CARE Measure items as very important to their consultation and the number of ‘not applicable’ and missing responses’ were low (2.6% and 0.1% respectively). The participating nurses had high CARE Measure scores; out of a maximum possible score of 50, the overall mean CARE measure score was 47.8 (standard deviation 4.4). The scores were moderately correlated with patient enablement (rho = 0.232, p = 0.001) and overall satisfaction (rho = 0.377, p = 0.001. Cronbach’s alpha showed the measure’s high internal consistency (Cronbach’s alpha coefficient = 0.95), but the inter-rater reliability could not be calculated due to the high achieved CARE Measure scores that varied little between nurses. Conclusions: Within this clinical context the CARE Measure has high perceived relevance and face validity. The findings support construct validity and some evidence of reliability. The high CARE Measure scores may have been due to sample bias. A future study which ensures a representative sample of patients on a larger group of nurses is required to determine whether the measure can discriminate between nurses

Measuring empathy in pediatrics: validation of the Visual CARE measure

Background: Empathy is a key element of “Patient and Family Centered Care”, a clinical approach recommended by the American Academy of Pediatrics. However, there is a lack of validated tools to evaluate paediatrician empathy. This study aimed to validate the Visual CARE Measure, a patient rated questionnaire measuring physician empathy, in the setting of a Pediatric Emergency Department (ED). Methods: The empathy of physicians working in the Pediatric ED of the University Hospital of Udine, Italy, was assessed using an Italian translation of the Visual Care Measure. This test has three versions suited to different age groups: the 5Q questionnaire was administered to children aged 7–11, the 10Q version to those older than 11, and the 10Q–Parent questionnaire to parents of children younger than 7. The internal reliability, homogeneity and construct validity of the 5Q and 10Q/10Q–Parent versions of the Visual Care Measure, were separately assessed. The influence of family background on the rating of physician empathy and satisfaction with the clinical encounter was also evaluated. Results: Seven physicians and 416 children and their parents were included in the study. Internal consistency measured by Cronbach’s alpha was 0.95 for the 10Q/10Q–Parent versions and 0.88 for the 5Q version. The item-total correlation was > 0.75 for each item. An exploratory factor analysis showed that all the items load onto the first factor. Physicians’ empathy scores correlated with patients’ satisfaction for both the 10Q and 10Q–Parent questionnaires (Spearman’s rho = 0.7189; p < 0.001) and for the 5Q questionnaire (Spearman’s rho = 0.5968; p < 0,001). Trust in the consulting physician was lower among immigrant parents (OR 0.43. 95% CI 0.20–0.93). Conclusions: The Visual Care Measure is a reliable second-person test of physician empathy in the setting of a Pediatric Emergency Room. More studies are needed to evaluate the reliability of this instrument in other pediatric settings distinct from the Emergency Room and to further evaluate its utility in measuring the impact of communication and empathy training programmes for healthcare professionals working in pediatrics

A qualitative study of the views on weight management in overweight and obese Chinese diabetic patients

Conference Theme: Stay Caring, Go Excelling in Primary CareFree Paper Competition – Poster Presentation 13 (abstracts)INTRODUCTION Weight reduction was found to be associated with improved glycemic control among overweight and obese adults with type 2 diabetes mellitus (DM). However, obesity and overweight remains a significant problem for diabetic patients, as their motivating factors and barriers for weight reduction are diverse and complex. This qualitative study aims to investigate the motivating factors and barriers in weight control among obese DM patients. METHOD Twenty in-depth semi-structured interviews with obese or overweight diabetic patients under the care of Ap Lei Chau Clinic were conducted in 2013/2014. Issues like perceived barriers, facilitators, and their experience in weight and DM management were explored. All the interviews were audio-taped and transcribed into English, typed verbatim. Grounded theory approach was adopted and saturated data were analyzed thematically. RESULTS Four key themes were identified: (1) patients’ medical conditions, (2) psychological factors, (3) social support and (4) lifestyle habits. Co-morbidities like OA knee hinder regular exercise. Self-perception of health and weight influences the compliance to weight control. Dieting is preferred over exercise for weight reduction. Social and family support can assist patients to monitor their weight and facilitate adherence to appropriate choices and amount at meals. Patients who tried nutritional counselling before often considered the advice form dietitians are unpractical and difficult to apply. DISCUSSION Lifestyle modifications play a significant role in weight management of DM patients. However, patients’ self-perception and support from family is equally important. Nutritional counselling should be more tailor-made for individual patients, and considering of co-morbidities is equally crucial