The ecology of medical care on an isolated island in Okinawa, Japan: a retrospective open cohort study

Abstract Background We aimed to describe the ecology of medical care on an isolated island with limited access to secondary care, and to evaluate the gatekeeping function of the island’s primary care clinic through comparison with a previous nationwide survey. Methods We conducted this retrospective, open cohort study on Iheya, an isolated island in Okinawa Prefecture that has one primary care clinic. We considered Iheya as unique location in which to examine the role of primary care in Japan. Participants were patients who visited the island’s clinic between February 1, 2013 and January 31, 2014. We calculated the number of visits to the clinic and referrals to off-island medical facilities using electronic medical records. We also compared data for Iheya with a nationwide survey conducted in 2003. Results Iheya had 1314 inhabitants in 2013. Of the 5682 visits to the clinic in the 1-year study period, 290 people were referred to off-island medical institutions. There were 64 referrals to emergency departments; of these, 57 people were admitted to hospital. The rate of visits to the clinic per month per 1000 inhabitants was 360.4 visits (95% confidence interval: 351.0–369.7). Of these, 18.4 (16.3–20.5) were referred off-island, with 4.1 (3.1–5.1) referrals to emergency departments and 3.6 (2.6–4.6) hospitalizations. Despite the high incidence of visits to the primary care clinic, the rates of hospital-based outpatient clinic visits, emergency department visits, and hospitalizations were lower than rates reported in a previous Japanese study. Conclusions This suggests that several dimensions of primary care, its gatekeeping function in particular, are likely to play important roles in this geographical setting

The ecology of medical care on an isolated island in Okinawa, Japan: a retrospective open cohort study.

BACKGROUND: We aimed to describe the ecology of medical care on an isolated island with limited access to secondary care, and to evaluate the gatekeeping function of the island's primary care clinic through comparison with a previous nationwide survey. METHODS: We conducted this retrospective, open cohort study on Iheya, an isolated island in Okinawa Prefecture that has one primary care clinic. We considered Iheya as unique location in which to examine the role of primary care in Japan. Participants were patients who visited the island's clinic between February 1, 2013 and January 31, 2014. We calculated the number of visits to the clinic and referrals to off-island medical facilities using electronic medical records. We also compared data for Iheya with a nationwide survey conducted in 2003. RESULTS: Iheya had 1314 inhabitants in 2013. Of the 5682 visits to the clinic in the 1-year study period, 290 people were referred to off-island medical institutions. There were 64 referrals to emergency departments; of these, 57 people were admitted to hospital. The rate of visits to the clinic per month per 1000 inhabitants was 360.4 visits (95% confidence interval: 351.0-369.7). Of these, 18.4 (16.3-20.5) were referred off-island, with 4.1 (3.1-5.1) referrals to emergency departments and 3.6 (2.6-4.6) hospitalizations. Despite the high incidence of visits to the primary care clinic, the rates of hospital-based outpatient clinic visits, emergency department visits, and hospitalizations were lower than rates reported in a previous Japanese study. CONCLUSIONS: This suggests that several dimensions of primary care, its gatekeeping function in particular, are likely to play important roles in this geographical setting

Adjustment and adaptation in patients with chronic heart failure at the end of life

Background: Advanced heart failure is receiving increasing attention from clinicians and policy makers as a major chronic condition associated with poor quality of life in an ageing population. Aim: To explore how we could tailor health interventions to individual patients with advanced heart failure at the end of life. Design: (1) A systematic review of national and international chronic heart failure guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and a data extraction framework based on the holistic needs assessment of the Gold Standards Framework (GSF). (2) A longitudinal qualitative study of 15 patients with New York Heart Association grade 3 or 4 heart failure recruited through two community based heart failure services. Semi-structured interviews were conducted with patients at 3 monthly intervals for 1 year (n= 52 interviews). A refined ‘case-based’ method as described by Griffiths et al. was adopted to identify the ideal type categories of adjustment and adaptation and assess how these categories change over time for each patient. This involved understanding individuals as complex systems, subject to internal and external influences, with the potential for transformation. The analysis drew on the theoretical concept of the emergent present - as developed by Adam - the current period of time when all domains of life have expression. Results: (1) A total of 19 guidelines were included in the review. Across all guidelines the lowest scoring domains were applicability and stakeholder involvement. Qualitative assessment showed that most guidelines adopt a disease-orientated approach to addressing need. In particular, domains on continuity of care and out of hours care were poorly covered. (2) Four distinct patterns of adjustment and adaptation were identified. The largest group was the Stuck and struggling category, which was characterised by participants wanting to move on but being unable to do so. Participants in the integrating group were able to accommodate the problems that they faced from moment to moment despite anticipating an uncertain future. Those in the submerged group were completely immersed in their illness and any expectation of a meaningful future had completely disappeared. The Past reminder group was characterised by a narrative based in the emergent present that was dominated by their experience of previous events. It was shown that some participants transformed from one category to another as a result of the care they received. For others, there was no change over the course of the study. Conclusion: This thesis identifies important differences between the ‘objective’ patient represented in clinical guidelines and the ‘subjective’ experience of the individual. The illness experiences of people living with advanced heart failure are diverse and do not lend themselves to standardised care. This raises important questions for the way knowledge is currently translated into clinical practice. Attending to the emergent present may be a clinically useful approach for supporting health care professionals to tailor care to needs of patients at the end of life

Evaluating the impact of differing completion rates of a face‐to‐face DIABETES self‐management education programme on Patient Reported Outcome measures ( DIABETES PRO ): A feasibility trial protocol

Introduction: Structured diabetes self‐management education (DSME) is internationally recommended for people with type 2 diabetes to support self‐management and to prevent associated long‐term complications. ‘Attendance’ at DSME is currently benchmarked as having completed a registration form and at least one active engagement with programme content, and ‘completion’ measured against ≥60% completion, despite landmark trials reporting outcomes based on the full completion of a programme. Little is known about the effectiveness of DSME on the psychological and emotional health of people with diabetes who complete less than the full DSME programme. We report a protocol for a single‐centre randomised feasibility study to assess the impact of differing completion rates of a face‐to‐face DSME programme on patient reported outcomes of self‐care, diabetes distress and quality of life in people with type 2 diabetes. Methods: A randomised feasibility study in 120 people with type 2 diabetes due to attend a secondary care diabetes clinic in the North West UK for DSME. Participants will be randomised into one of the four groups: Group 1 full DSME programme, Group 2 60%, Group 3 10% and Group 4 0% (delayed education). Psychometric questionnaire scores will be evaluated at baseline and 3–4 months post‐intervention. Measures of feasibility (eligibility, recruitment and retention rates) will be reported. Ethics and Dissemination: The DIABETES‐PRO study was approved by the London–Surrey Borders Research Ethics Committee (24/LO/0235). Results will be shared with study participants and published in peer‐reviewed journals. Trial Registration: Clinicaltrials.gov NCT06419907

Current and future advances in practice: tendinopathies of the shoulder

Tendinopathies of the shoulder are a burdensome problem. Current treatments include exercise, physical therapies, corticosteroid injections, and surgery. However, the clinical outcomes from randomised controlled trials evaluating the effectiveness of these interventions are largely unremarkable. Given the apparent lack of progress in improving clinical outcomes for patients, it is appropriate to consider other avenues. Research has identified a link between lifestyle-related modifiable risk factors including smoking, overweight, physical inactivity, and the onset and persistence of tendinopathies of the shoulder. Further research is required to understand whether addressing these factors results in better clinical outcomes for patients. Teachable moments and shared decision-making are concepts that could enable clinicians to integrate the assessment and management of these lifestyle factors. Given these lifestyle factors also increase the risk of developing other common morbidities, including cardiovascular disease, an evolution of routine clinical care in this way could represent an important step forward

HIV prevalence and characteristics of sex work among female sex workers in Hargeisa, Somaliland, Somalia.

OBJECTIVE: To measure prevalence of HIV and syphilis and describe characteristics of sex work among female sex workers (FSWs) in Hargeisa, Somaliland, Somalia. METHODS: A cross-sectional survey recruited 237 FSWs using respondent-driven sampling (RDS). A face-to-face, structured interview using handheld-assisted personal interviewing (HAPI) on personal digital assistants (PDAs) was completed and blood collected for serological testing. RESULTS: FSWs 15-19 years old accounted for 6.9% of the population; 20-24 year-old constituted an additional 18.0%. The majority (86.6%) never attended school. International (59.0%) and interzonal (10.7%) migration was common. Most (95.7%) reported no other source of income; 13.8% had five or more clients in the last 7 days. A minority (38.4%) had heard of STIs, even fewer (6.9%) held no misconceptions about HIV. Only 24% of FSW reported using a condom at last transactional sex, and 4% reported ever been tested for HIV. HIV prevalence was 5.2% and syphilis prevalence was 3.1%. CONCLUSION: Sex work in Hargeisa, Somaliland, Somalia, is characterized by high numbers of sexual acts and extremely low knowledge of HIV. This study illustrates the need for targeted HIV prevention interventions focusing on HIV testing, risk-reduction awareness raising, and review of condom availability and distribution mechanisms among FSWs and males engaging with FSWs

Which cuff should I use? Indirect blood pressure measurement for the diagnosis of hypertension in patients with obesity: a diagnostic accuracy review.

OBJECTIVE: To determine the diagnostic accuracy of different methods of blood pressure (BP) measurement compared with reference standards for the diagnosis of hypertension in patients with obesity with a large arm circumference. DESIGN: Systematic review with meta-analysis with hierarchical summary receiver operating characteristic models. Bland-Altman analyses where individual patient data were available. Methodological quality appraised using Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS2) criteria. DATA SOURCES: MEDLINE, EMBASE, Cochrane, DARE, Medion and Trip databases were searched. ELIGIBILITY CRITERIA: Cross-sectional, randomised and cohort studies of diagnostic test accuracy that compared any non-invasive BP tests (upper arm, forearm, wrist, finger) with an appropriate reference standard (invasive BP, correctly fitting upper arm cuff, ambulatory BP monitoring) in primary care were included. RESULTS: 4037 potentially relevant papers were identified. 20 studies involving 26 different comparisons met the inclusion criteria. Individual patient data were available from 4 studies. No studies satisfied all QUADAS2 criteria. Compared with the reference test of invasive BP, a correctly fitting upper arm BP cuff had a sensitivity of 0.87 (0.79 to 0.93) and a specificity of 0.85 (0.64 to 0.95); insufficient evidence was available for other comparisons to invasive BP. Compared with the reference test of a correctly fitting upper arm cuff, BP measurement at the wrist had a sensitivity of 0.92 (0.64 to 0.99) and a specificity of 0.92 (0.85 to 0.87). Measurement with an incorrectly fitting standard cuff had a sensitivity of 0.73 (0.67 to 0.78) and a specificity of 0.76 (0.69 to 0.82). Measurement at the forearm had a sensitivity of 0.84 (0.71 to 0.92) and a specificity 0.75 of (0.66 to 0.83). Bland-Altman analysis of individual patient data from 3 studies comparing wrist and upper arm BP showed a mean difference of 0.46 mm Hg for systolic BP measurement and 2.2 mm Hg for diastolic BP measurement. CONCLUSIONS: BP measurement with a correctly fitting upper arm cuff is sufficiently sensitive and specific to diagnose hypertension in patients with obesity with a large upper arm circumference. If a correctly fitting upper arm cuff cannot be applied, an incorrectly fitting standard size cuff should not be used and BP measurement at the wrist should be considered