Patients' opinion on the barriers to diabetes control in areas of conflicts: The Iraqi example

<p>Abstract</p> <p>Background</p> <p>The health system in Iraq has undergone progressive decline since the embargo that followed the second gulf war in 1991. The aim of this study is to see barriers to glycemic control form the patient perspective, in a diabetic clinic in the south of Iraq.</p> <p>Methods</p> <p>A cross sectional study from the diabetes out-patient clinic in Al-Faiha general hospital in Basrah, South Iraq for the period from January to December 2007. The study includes diabetic patients whether type 1 or 2 if they have at least one year of follow up in the same clinic. Those with A1C ≥ 7% were interviewed by special questionnaire, that was filled in by the medical staff of the clinic. The subjects analyzed in this study were adults (≥ 18 years old) with previously diagnosed diabetes (n = 3522). The duration of diabetes range from 1 to 30 years.</p> <p>Results</p> <p>Mean A1C was 8.4 ± 2 percent, with 835(23.7%) patients with A1C less than 7% and 2688(76.3%) equal to or more than 7%. Of 3522 studied patients, 46.6% were men and 51.5% were women, with mean age of 53.78 ± 12.81 year and age range 18–97 years. Patient opinion for not achieving good glycemic control among 2688 patients with HbA1C ≥ 7% included the following. No drug supply from primary health care center (PHC) or drug shortage is a cause in 50.8% of cases, while drugs and or laboratory expense were the cause in 50.2%. Thirty point seven percent of patients said that they were unaware of diabetics complications and 20.9% think that diabetes is an untreatable disease. Thirty percent think that non-control of their diabetes is due to migration after the war. No electricity or erratic electricity, self-monitoring of blood glucose (SMBG) is not available, or strips were not available or could not be used, and illiteracy as a cause was seen in 15%, 10.8% and 9.9% respectively.</p> <p>Conclusion</p> <p>Our patients with diabetes mellitus declared that of the causes for poor glycemic control most of them related to the current health situation in Iraq.</p

The effects of patient characteristics on ADHD diagnosis and treatment: a factorial study of family physicians

<p>Abstract</p> <p>Background</p> <p>Attention Deficit Hyperactivity Disorder (ADHD) is a costly and prevalent disorder in the U.S., especially among youth. However, significant disparities in diagnosis and treatment appear to be predicted by the race and insurance status of patients.</p> <p>Methods</p> <p>This study employed a web-based factorial survey with four ADHD cases derived from an ADHD clinic, two diagnosed with ADHD in actual evaluation, and two not. Randomized measures included race and insurance status of the patients. Participants N = (187) included clinician members of regional and national practice-based research networks and the U.S. clinical membership of the Society of Teachers of Family Medicine. The main outcomes were decisions to 1) diagnose and 2) treat the cases, based upon the information presented, analyzed via binary logistic regression of the randomized factors and case indicators on diagnosis and treatment.</p> <p>Results</p> <p>ADHD-positive cases were 8 times more likely to be diagnosed and 12 times more likely to be treated, and the male ADHD positive case was more likely to be diagnosed and treated than the female ADHD positive case. Uninsured cases were significantly more likely to be treated overall, but male cases that were uninsured were about half as likely to be diagnosed and treated with ADHD. Additionally, African-American race appears to increase the likelihood of medicinal treatment for ADHD and being both African-American and uninsured appears to cut the odds of medicinal treatment in half, but not significantly.</p> <p>Conclusions</p> <p>Family physicians were competent at discerning between near-threshold ADHD-negative and ADHD positive cases. However, insurance status and race, as well as gender, appear to affect the likelihood of diagnosis and treatment for ADHD in Family Medicine settings.</p

Is race medically relevant? A qualitative study of physicians' attitudes about the role of race in treatment decision-making

<p>Abstract</p> <p>Background</p> <p>The role of patient race in medical decision-making is heavily debated. While some evidence suggests that patient race can be used by physicians to predict disease risk and determine drug therapy, other studies document bias and stereotyping by physicians based on patient race. It is critical, then, to explore physicians' attitudes regarding the medical relevance of patient race.</p> <p>Methods</p> <p>We conducted a qualitative study in the United States using ten focus groups of physicians stratified by self-identified race (black or white) and led by race-concordant moderators. Physicians were presented with a medical vignette about a patient (whose race was unknown) with Type 2 diabetes and untreated hypertension, who was also a current smoker. Participants were first asked to discuss what medical information they would need to treat the patient. Then physicians were asked to explicitly discuss the importance of race to the hypothetical patient's treatment. To identify common themes, codes, key words and physician demographics were compiled into a comprehensive table that allowed for examination of similarities and differences by physician race. Common themes were identified using the software package NVivo (QSR International, v7).</p> <p>Results</p> <p>Forty self-identified black and 50 self-identified white physicians participated in the study. All physicians - regardless of their own race - believed that medical history, family history, and weight were important for making treatment decisions for the patient. However, black and white physicians reported differences in their views about the relevance of race. Several black physicians indicated that patient race is a central factor for choosing treatment options such as aggressive therapies, patient medication and understanding disease risk. Moreover, many black physicians considered patient race important to understand the patient's views, such as alternative medicine preferences and cultural beliefs about illness. However, few white physicians explicitly indicated that the patient's race was important over-and-above medical history. Instead, white physicians reported that the patient should be treated aggressively regardless of race.</p> <p>Conclusions</p> <p>This investigation adds to our understanding about how physicians in the United States consider race when treating patients, and sheds light on issues physicians face when deciding the importance of race in medical decision-making.</p

Improving patient adherence to lifestyle advice (IMPALA): a cluster-randomised controlled trial on the implementation of a nurse-led intervention for cardiovascular risk management in primary care (protocol)

Background Many patients at high risk of cardiovascular diseases are managed and monitored in general practice. Recommendations for cardiovascular risk management, including lifestyle change, are clearly described in the Dutch national guideline. Although lifestyle interventions, such as advice on diet, physical exercise, smoking and alcohol, have moderate, but potentially relevant effects in these patients, adherence to lifestyle advice in general practice is not optimal. The IMPALA study intends to improve adherence to lifestyle advice by involving patients in decision making on cardiovascular prevention by nurse-led clinics. The aim of this paper is to describe the design and methods of a study to evaluate an intervention aimed at involving patients in cardiovascular risk management. Methods A cluster-randomised controlled trial in 20 general practices, 10 practices in the intervention arm and 10 in the control arm, starting on October 2005. A total of 720 patients without existing cardiovascular diseases but eligible for cardiovascular risk assessment will be recruited. In both arms, the general practitioners and nurses will be trained to apply the national guideline for cardiovascular risk management. Nurses in the intervention arm will receive an extended training in risk assessment, risk communication, the use of a decision aid and adapted motivational interviewing. This communication technique will be used to support the shared decision-making process about risk reduction. The intervention comprises 2 consultations and 1 follow-up telephone call. The nurses in the control arm will give usual care after the risk estimation, according to the national guideline. Primary outcome measures are self-reported adherence to lifestyle advice and drug treatment. Secondary outcome measures are the patients' perception of risk and their motivation to change their behaviour. The measurements will take place at baseline and after 12 and 52 weeks. Clinical endpoints will not be measured, but the absolute 10-year risk of cardiovascular events will be estimated for each patient from medical records at baseline and after 1 year. Discussion The combined use of risk communication, a decision aid and motivational interviewing to enhance patient involvement in decision making is an innovative aspect of the intervention. Trial registration Current Controlled Trials ISRCTN5155672

Diagnostic Certainty as a Source of Medical Practice Variation in Coronary Heart Disease: Results from a Cross-National Experiment of Clinical Decision Making

The authors examined physician diagnostic certainty as one reason for cross-national medical practice variation. Data are from a factorial experiment conducted in the United States, the United Kingdom, and Germany, estimating 384 generalist physicians’ diagnostic and treatment decisions for videotaped vignettes of actor patients depicting a presentation consistent with coronary heart disease (CHD). Despite identical vignette presentations, the authors observed significant differences across health care systems, with US physicians being the most certain and German physicians the least certain (P < 0.0001). Physicians were least certain of a CHD diagnoses when patients were younger and female (P < 0.0086), and there was additional variation by health care system (as represented by country) depending on patient age (P < 0.0100) and race (P < 0.0021). Certainty was positively correlated with several clinical actions, including test ordering, prescriptions, referrals to specialists, and time to follow-up

Educação terapêutica para diabéticos: os cuidados com os pés na realidade de pacientes e familiares Therapeutic education for diabetics: foot care in the reality of patients and family members

Conhecer a realidade da prática dos cuidados com os pés ensinados nos programas educativos para diabéticos pode contribuir para um melhor resultado da educação terapêutica. Este estudo apresenta significados atribuídos por pacientes diabéticos e seus familiares aos cuidados primários que visam prevenir complicações nos pés. Foi realizada uma pesquisa qualitativa exploratória sobre amostra intencional de trinta diabéticos, neuropatas, com risco de lesão nos pés e familiares de onze deles, que participaram de um programa de prevenção em uma unidade de saúde pública do município de Porto Alegre (RS). Foi aplicada uma entrevista semidirigida com questões abertas sobre a experiência dos cuidados com os pés. O material transcrito foi submetido à análise qualitativa de conteúdo. Os pacientes precisam de ajuda para realizar os cuidados com os pés. Uma rede de solidariedade e interações é formada por trás dos pacientes, percebida como um apoio ou uma ameaça à liberdade. É a experiência própria ou alheia de uma complicação que evidencia a importância da prevenção. A educação terapêutica para prevenção de complicações nos pés de diabéticos deve levar em conta as relações de assistência formadas em torno do doente. É preciso romper o silêncio da evolução da doença para motivar o paciente à adoção das medidas preventivas.<br>Knowing the reality of foot care practice taught in educational programs for diabetics can enhance the therapeutic education success. This study presents the perceptions of diabetics and their family members about primary cares to prevent complications on foot. A qualitative exploratory study was conducted in an intentional sample of 30 diabetic with neuropathic risk of foot injuries as well as 11 of their family members, participants of a preventive program offered in a public health center in the city of Porto Alegre, Rio Grande do Sul State, Brazil. A semi-structured interview with open-ended questions about experiences of foot care was conducted. The material transcribed was submitted to qualitative content analyses. Patients need assistance to foot care practice. A cooperative and interactive network is formed behind patients, perceived as a support or a threat to freedom. The importance of preventive measures becomes evident from their personal experiences of a complication or those of others'. Therapeutic education to prevent diabetic foot complications must consider the relations of assistance formed around the patient. It is necessary to break the silence of the evolution of the disease in order to motivate the patient to the adoption of preventive measures

Implicit bias in healthcare professionals: a systematic review

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients