Economic consequences of near-patient test results - the case of tests for the Helicobacter Pylori bacterium in dyspepsia

Abstract Diagnostic tests and in particular laboratory tests are often important in diagnostic work-up and monitoring of patients. Therefore the economic consequences of medical actions based on test results may amount to a substantial proportion of health service costs. Thus, it is of public interest to study the consequences and costs of using laboratory tests. We develop a model for economic evaluation related to the diagnostic accuracy (sensitivity and specificity) of near patient tests. Blood sample based tests to detect the bacterium Helicobacter Pylori (HP) are useful in diagnosing peptic ulcer and suitable to illustrate the model. First, general practitioners’ initial management plans for a dyspeptic patient are elucidated using a paper vignette survey. Based on survey results, and medical literature, a decision tree is constructed to visualize expected costs and outcomes resulting from using three different HP tests in the clinical situation described in the vignette. Tests included are two rapid tests for use in general practice, and one hospital laboratory test for comparison. The tests had different sensitivities and specificities. Then a costeffectiveness analysis is undertaken from a societal perspective. Finally we use sensitivity analyses to model the decision uncertainty. Estimating for a follow-up period of 120 days, the rapid test with lower sensitivity and specificity than the hospital HP test is cost-effective because the laboratory result is available immediately. Further, in general practice, the rapid test with the highest sensitivity is significantly cost effective compared to the test with the highest specificity when the willingness to pay for each dyspepsia-free day exceeds €42.6. When deciding whether a laboratory analysis should be analysed in the office laboratory or not, it is important to consider both the diagnostic accuracy of the tests and the waiting time for the alternative, i.e. a hospital laboratory result.cost-effectiveness; laboratory tests; general practice; probabilistic sensitivity; analysis

Decision-making in General Practice: The importance of laboratory analyses when choosing medical actions

The focus of this study is the effect of a laboratory analysis and socioeconomic variables on choosing medical actions in a specific situation (a clinical vignette - a young woman, Mrs Hansen, with dyspepsia - presented to GPs). We assume that the GP’s decision depends on what he or she thinks is best for the patients, based on the best clinical evidence available. Significant variables associated with the choice of medical actions are: the result of the Helicobacter pylori (HP) test, the GP’s stated importance of HPRT, the location of the general practice, the GP recommending sick leave, the GP’s stated probability that Mrs Hansen’s symptoms are due to a H.pylori infection after the HP-result is known, and how the GP follows up the patient. Our results show that the HP-analysis has a significant and major influence on the GPs choice of medical actions. Therefore the quality of the analysis is likely to affect the patients’ health and social costs. Hence institutions for quality monitoring and improvement are important elements of health care reforms. Such institutions should balance cost and benefits of quality improving measures, and will be the focus of closer studies in our future research.Discrete choice models; Decision-making; Primary Health Care

Scanning activity of elite football players in 11 vs. 11 match play: An eye-tracking analysis on the duration and visual information of scanning

Visual perception in football (“soccer” in the U.S.) is increasingly becoming a key area of interest for researchers and practitioners. This exploratory case study investigated a sub-set of visual perception, namely visual exploratory scanning. The aim of this study was to examine the scanning of four elite football midfield players in an 11 vs. 11 real-game environment using mobile eye-tracking technology. More specifically, we measured the duration and information (number of teammates and opponents) of the players’ scanning behavior. The results showed that the players’ scanning duration was influenced by the ball context and the action undertaken with the ball at the moment of scan initiation. Furthermore, fixations were found in only 2.3% of the scans. Additionally, the results revealed that the stop point is the most information-rich part of a scan and that the players had more opponents than teammates inside their video frame during scans. Practical applications and further research recommendations are presented

Improving drug prescription in general practice using a novel quality improvement model

Introduction Quality improvement (QI) clusters have been established in many countries to improve healthcare using the Breakthrough Series’ collaboration model. We investigated the effect of a novel QI approach based on this model of performed medication reviews and drug prescription in a Norwegian municipality. Methods All 27 General Practitioners (GPs) in a mid-size Norwegian municipality were invited to join the intervention, consisting of three peer group meetings during a period of 7–8 months. Participants learned practical QI skills by planning and following up QI projects within drug prescription practice. Evaluation forms were used to assess participants’ self-rated improvement, reported medication review reimbursement codes (MRRCs) were used as a process measure, and defined daily doses (DDDs) of potentially inappropriate drugs (PIDs) dispensed to patients aged 65 years or older were used as outcome measures. Results Of the invited GPs, 25 completed the intervention. Of these, 76% self-reported improved QI skills and 67% reported improved drug prescription practices. Statistical process control revealed a non-random increase in the number of MRRCs lasting at least 7 months after intervention end. Compared with national average data, we found a significant reduction in dispensed DDDs in the intervention municipality for benzodiazepine derivates, benzodiazepine-related drugs, drugs for urinary frequency and incontinence and non-steroid anti-inflammatory and antirheumatic medications. Conclusion Intervention increased the frequency of medication reviews, resulting in fewer potentially inappropriate prescriptions. Moreover, there was self-reported improvement in QI skills in general, which may affect other practice areas as well. Intervention required relatively little absence from clinical practice compared with more traditional QI interventions and could, therefore, be easier to implement. KEY POINT The current study investigated to what extent a novel model based on the Breakthrough Series’ collaborative model affects GP improvement skills in general practice and changes their drug prescription. KEY FINDINGS Most participants reported better improvement skills and improved prescription practice. The number of dispensed potentially inappropriate drugs decreased significantly in the intervention municipality compared with the national average. The model seemed to lead to sustained changes after the end of the intervention.publishedVersio

Variation between general practitioners in type 2 diabetes processes of care

Aims To explore variation in general practitioners’ (GPs’) performance of six recommended procedures in type 2 diabetes patients <75 years without cardiovascular disease. Methods Cross-sectional study of quality of diabetes care in Norway based on electronic health records from 2014. GPs (clustered in practices) were divided in quintiles based on a composite measure of performance of six processes of care. We fitted a multilevel partial ordinal regression model to identify GP factors associated with being in quintiles with better performance. Results We identified 6015 type 2 diabetes patients from 275 GPs in 77 practices. The GPs performed on average 63.4% of the procedures; on average 46% in the poorest quintile to 81% in the best quintile with a larger range in individual GPs. After adjustments, use of a structured follow-up form was associated with GPs being in upper three quintiles (OR 12.4 (95% CI 2.37–65.1). Routines for reminders were associated with being in a better quintile (OR 2.6 (1.37–4.92). GPs’ age >60 years and heavier workload were associated with poorer performance. Conclusion We found large variations in GPs’ performance of processes of care. Factors reflecting structure and workload were strongly associated with performance.publishedVersio

What Do Football Players Look at? An Eye-Tracking Analysis of the Visual Fixations of Players in 11 v 11 Elite Football Match Play

Current knowledge of gaze behavior in football has primarily originated from eye-tracking research in laboratory settings. Using eye-tracking with elite players in a real-world 11 v 11 football game, this exploratory case study examined the visual fixations of midfield players in the Norwegian premier league. A total of 2,832 fixations by five players, aged 17–23 years (M = 19.84), were analyzed. Our results show that elite football midfielders increased their fixation duration when more information sources became available to them. Additionally, participants used shorter fixation durations than previously reported in laboratory studies. Furthermore, significant differences in gaze behavior between the attack and defense phases were found for both areas of interest and fixation location. Lastly, fixation locations were mainly on the ball, opponent, and teammate category and the player in possession of the ball. Combined, the results of this study enhance the knowledge of how elite footballers use their vision when playing under actual match-play conditions. They also suggest that laboratory designs may not be able to capture the dynamic environment that footballers experience in competition

Feasibility of using self-reported patient data in a national diabetes register

Background: In order to improve recruitment of patients to the Norwegian diabetes register for adults, a questionnaire was designed to collect data directly from patients. The main aim of this study was to assess the agreement of questionnaire data with data reported to the Register from health care personnel during routine consultations. Methods: Patient data were obtained by sending a questionnaire with 27 of the 41 Register variables to 3714 members of the Norwegian Diabetes Association. Questionnaire data were compared with data already in the Register. Paired t-tests, percentages of total agreement, percentages of “positive” answers and kappa coefficients (k) were used for comparing data. Results: Of the 1645 replies (44.3 %), the Register already had data on 324 patients for comparison. Response rate for most variables was better from patients (ranging from 76–100 %) compared with health care professionals (33–100 %). For 17 of 25 assessable variables including diabetes duration, height, weight, HbA1c, drug treatment and several diabetes complications, agreement was substantial or better with kappa >0.60. Data on family history of premature heart disease (k–0.59), foot examination (k = 0.26), foot ulcer (k = 0.32) and arterial surgery (k = 0.24) seemed to be difficult to answer by patients, whereas data on physical activity and self-monitoring of glucose seemed to be better when reported by patients. Conclusions: Patient response rate was acceptable, and data had good concordance with data from health care professionals for most variables. However, registers using patient questionnaires should compare questionnaire data with data from professionals at regular intervals

Warfarin monitoring in nursing homes assessed by case histories. Do recommendations and electronic alerts affect judgements?

Purpose: Older adults treated with warfarin are prone to complications, and high-quality monitoring is essential. The aim of this case history based study was to assess the quality of warfarin monitoring in a routine situation, and in a situation with an antibiotic–warfarin interaction, before and after receiving an electronic alert. Materials and methods: In April 2014, a national web-based survey with two case histories was distributed among Norwegian nursing home physicians and general practitioners working part-time in nursing homes. Case A represented a patient on stable warfarin treatment, but with a substantial INR increase within the therapeutic interval. Case B represented a more challenging patient with trimethoprim sulfamethoxazole (TMS) treatment due to pyelonephritis. In both cases, the physicians were asked to state the next warfarin dose and the INR recall interval. In case B, the physicians could change their suggestions after receiving an electronic alert on the TMS-warfarin interaction. Results: Three hundred and ninety eight physicians in 292 nursing homes responded. Suggested INR recall intervals and warfarin doses varied substantially in both cases. In case A, 61% gave acceptable answers according to published recommendations, while only 9% did so for case B. Regarding the TMS-warfarin interaction in case history B, the electronic alert increased the percentage of respondents correctly suggesting a dose reduction from 29% to 53%. Having an INR instrument in the nursing home was associated with shortened INR recall times. Conclusions: Practical advice on handling of warfarin treatment and drug interactions is needed. Electronic alerts as presented in electronic medical records seem insufficient to change practice. Availability of INR instruments may be important regarding recall time