Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study

<p>Abstract</p> <p>Background</p> <p>Self-management support is seen as a cornerstone of good diabetes care and many countries are currently engaged in initiatives to integrate self-management support in primary care. Concerning the organisation of these programs, evidence is growing that engagement of health care professionals, in particular of GPs, is critical for successful application. This paper reports on a study exploring why a substantial number of GPs was (initially) reluctant to refer patients to a self-management education program in Belgium.</p> <p>Methods</p> <p>Qualitative analysis of semi-structured face-to-face interviews with a purposive sample of 20 GPs who were not regular users of the service. The Greenhalgh diffusion of innovation framework was used as background and organising framework.</p> <p>Results</p> <p>Several barriers, linked to different components of the Greenhalgh model, emerged from the interview data. One of the most striking ones was the limited readiness for innovation among GPs. Feelings of fear of further fragmentation of diabetes care and frustration and insecurity regarding their own role in diabetes care prevented them from engaging in the innovation process. GPs needed time to be reassured that the program respects their role and has an added value to usual care. Once GPs considered referring patients, it was not clear enough which of their patients would benefit from the program. Some GPs expressed the need for training in motivational skills, so that they could better motivate their patients to participate. A practical but often mentioned barrier was the distance to the centre where the program was delivered. Further, uncertainty about continuity interfered with the uptake of the offer.</p> <p>Conclusions</p> <p>The study results contribute to a better understanding of the reasons why GPs hesitate to refer patients to a self-management education program. First of all, the role of GPs and other health care providers in diabetes care needs to be clarified before introducing new functions. Feelings of security and a basic trust of providers in the health system are a prerequisite for participation in care innovation. Moreover, some important lessons regarding the implementation of an education program in primary care have been learned from the study.</p

Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany

<p>Abstract</p> <p>Background</p> <p>Growing interest in multimorbidity is observable in industrialized countries. For Germany, the increasing attention still goes still hand in hand with a small number of studies on multimorbidity. The authors report the first results of a cross-sectional study on a large sample of policy holders (n = 123,224) of a statutory health insurance company operating nationwide. This is the first comprehensive study addressing multimorbidity on the basis of German claims data. The main research question was to find out which chronic diseases and disease combinations are specific to multimorbidity in the elderly.</p> <p>Methods</p> <p>The study is based on the claims data of all insured policy holders aged 65 and older (n = 123,224). Adjustment for age and gender was performed for the German population in 2004. A person was defined as multimorbid if she/he had at least 3 diagnoses out of a list of 46 chronic conditions in three or more quarters within the one-year observation period. Prevalences and risk-ratios were calculated for the multimorbid and non-multimorbid samples in order to identify diagnoses more specific to multimorbidity and to detect excess prevalences of multimorbidity patterns.</p> <p>Results</p> <p>62% of the sample was multimorbid. Women in general and patients receiving statutory nursing care due to disability are overrepresented in the multimorbid sample. Out of the possible 15,180 combinations of three chronic conditions, 15,024 (99%) were found in the database. Regardless of this wide variety of combinations, the most prevalent individual chronic conditions do also dominate the combinations: Triads of the six most prevalent individual chronic conditions (hypertension, lipid metabolism disorders, chronic low back pain, diabetes mellitus, osteoarthritis and chronic ischemic heart disease) span the disease spectrum of 42% of the multimorbid sample. Gender differences were minor. Observed-to-expected ratios were highest when purine/pyrimidine metabolism disorders/gout and osteoarthritis were part of the multimorbidity patterns.</p> <p>Conclusions</p> <p>The above list of dominating chronic conditions and their combinations could present a pragmatic start for the development of needed guidelines related to multimorbidity.</p

Assessment of cure by detection of circulating antigens in serum and urine, following schistosomiasis mass treatment in two villages of the Office du Niger, Mali

Eight weeks after mass chemotherapy with 40 mg/kg praziquantel in two villages in Office du Niger (an irrigation area in Mali, endemic for both Schistosoma haematobium and Schistosoma mansoni) the circulating anodic (CAA) and cathodic (CCA) antigen detection assays were carried out on serum and urine samples. Both prior and post treatment highest prevalence was measured with the urine-CCA assay. Cure rates determined by antigen detection were almost half that of the egg counting methods. It was shown that the reduction in intensity should be preferentially assessed by the serum-CAA assay. Compared with egg detection, a single antigen detection assay gave a much better assessment of the impact of chemotherapy. PIP: Surveys conducted in different regions of Mali, to compare the circulating anodic antigen (CAA) and circulating cathodic antigen (CCA) detection assays with the classical method of parasitologic egg counting in the diagnosis of schistosomiasis, found the highest sensitivity with the urine CCA assay. The present study investigated cure rates in a mixed Schistosoma haematobium/S. mansoni endemic area by applying the CAA and CCA assays on 97 serum and urine specimens from Dogon, Mali. 8 weeks after mass treatment with 40 mg/kg of praziquantel, the cure rate was 87% according to 2 urine egg counts and 96% as determined by a single stool egg count. Both before and after treatment, the highest prevalence was again measured by the urine CCA assay. Cure rates determined by antigen detection were almost one-half that of the egg counting method. Reduction in intensity, as determined by serum CAA concentrations, was above 90% in both villages in the study area. The urine CCA assay, however, showed a reduction in intensity in one site and an increase in the other. These results suggest that the serum CAA assay should be used preferentially to assess the reduction in intensity, since serum antigen levels reflect worm burdens more directly than those in urine, given their influence by renal excretion dynamics. Timing of cure rate determination by using antigen detection should take into account local transmission patterns

Circulating anodic and cathodic antigen in serum and urine of mixed Schistosoma haematobium and S. mansoni infections in Office du Niger, Mali

In Office du Niger, an area endemic for both Schistosoma haematobium and S. mansoni in Mali, circulating anodic (CAA) and cathodic (CCA) antigen detection assays were performed on pretreatment serum and urine samples from two villages, Rigandé and Siguivoucé, and compared with egg counting methods. The highest prevalence was obtained with the urine-CCA assay which also had the highest sensitivity to S. haematobium, S. mansoni or mixed infection. A single urine-CCA assay was as sensitive as repeated egg counts (one stool+two urine examinations per individual). When the different assays were tested in parallel, several combinations including assays on serum were found to be highly sensitive. As urine sampling is widely accepted, urine assays will be used for further monitoring these villages one and two years after chemotherapy

Optical properties of isolated and covalent organic framework-embedded ruthenium complexes

Heterogenization of RuL3 complexes on a support with proper anchor points provides a route toward design of green catalysts. In this paper, Ru(II) polypyridyl complexes are investigated with the aim to unravel the influence on the photocatalytic properties of varying nitrogen content in the ligands and of embedding the complex in a triazine-based covalent organic framework. To provide fundamental insight into the electronic mechanisms underlying this behavior, a computational study is performed. Both the ground and excited state properties of isolated and anchored ruthenium complexes are theoretically investigated by means of density functional theory and time-dependent density functional theory. Varying the ligands among 2,2\u2032-bipyridine, 2,2\u2032-bipyrimidine, and 2,2\u2032-bipyrazine allows us to tune to a certain extent the optical gaps and the metal to ligand charge transfer excitations. Heterogenization of the complex within a CTF support has a significant effect on the nature and energy of the electronic transitions. The allowed transitions are significantly red-shifted toward the near IR region and involve transitions from states localized on the CTF toward ligands attached to the ruthenium. The study shows how variations in ligands and anchoring on proper supports allows us to increase the range of wavelengths that may be exploited for photocatalysis