Variations régionales du recours aux soins: quelques problèmes méthodologiques. [Regional variations in health services: various methodological problems].

Many studies show strong variation of health consumption between regions, suggesting that theses variations are related to the uncertainty of medical practice or to other factors related to health services or patients attitude. However the statistical interpretation of these variations is far from easy: apart from usual and specific information bias, there are statistical problems when observing incidence of events like health care consumption: it is in fact a rare event, which is observed within small population, and among regions with unequal number of person. Therefore, most of the variation reported might be well explained by a purely statistical phenomenon. This paper presents some aspects of this variability for three common indicators of variation, and suggest the use of ad hoc simulation to get statistical criteria.

Alternativas de tratamiento para el cáncer de próstata : ¿qué opción prefiero? : instrumento de ayuda para la toma de decisiones

Publicado en la página web de la Consejería de Salud y Bienestar Social: www.juntadeandalucia.es/salud (Consejería de Salud y Bienestar Social / Ciudadanía / Nuestro Compromiso por la Calidad / Guías de información para pacientes). Documento para la ciudadanía relacionado con el Proceso Asistencial Integrado : Cáncer de próstata

Alternativas de tratamiento para el cáncer de mama : ¿qué opción prefiero? : instrumento de ayuda para la toma de decisiones

Publicado en la página web de la Consejería de Salud y Bienestar Social: www.juntadeandalucia.es/salud (Consejería de Salud y Bienestar Social / Ciudadanía / Nuestro Compromiso por la Calidad / Guías de información para pacientes). Documento para la ciudadanía relacionado con el Proceso Asistencial Integrado : Cáncer de mama

Freedom of choice of specialist physicians is important to Swiss resident: a cross-sectional study.

QUESTION UNDER STUDY: To assess how important the possibility to choose specialist physicians is for Swiss residents and to determine which variables are associated with this opinion. METHODS: This cross-sectional study used data from the 2007 Swiss population-based health survey and included 13,642 non-institutionalised adults who responded to the telephone and paper questionnaires. The dependent variable included answers to the question "How important is it for you to be able to choose the specialist you would like to visit?" Independent variables included socio-demographics, health and past year healthcare use measures. Crude and adjusted logistic regressions for the importance of being able to choose specialist physicians were performed, accounting for the survey design. RESULTS: 45% of participants found it very important to be able to choose the specialist physician they wanted to visit. The answers "rather important", "rather not important" and "not important" were reported by 28%, 20% and 7% of respondents. Women, individuals in middle/high executive position, those with an ordinary insurance scheme, those reporting ≥2 chronic conditions or poorer subjective health, or those who had had ≥2 outpatient visits in the preceding year were more likely to find this choice very important. CONCLUSIONS: In 2007, almost half of all Swiss residents found it very important to be able to choose his/her specialist physician. The further development of physician networks or other chronic disease management initiatives in Switzerland, towards integrated care, need to pay attention to the freedom of choice of specialist physicians that Swiss residents value. Future surveys should provide information on access and consultations with specialist physicians.

Eligibility for and outcome of treatment of latent tuberculosis infection in a cohort of HIV-infected people in Spain

BACKGROUND Previous studies have demonstrated the efficacy of treatment for latent tuberculosis infection (TLTBI) in persons infected with the human immunodeficiency virus, but few studies have investigated the operational aspects of implementing TLTBI in the co-infected population.The study objectives were to describe eligibility for TLTBI as well as treatment prescription, initiation and completion in an HIV-infected Spanish cohort and to investigate factors associated with treatment completion. METHODS Subjects were prospectively identified between 2000 and 2003 at ten HIV hospital-based clinics in Spain. Data were obtained from clinical records. Associations were measured using the odds ratio (OR) and its 95% confidence interval (95% CI). RESULTS A total of 1242 subjects were recruited and 846 (68.1%) were evaluated for TLTBI. Of these, 181 (21.4%) were eligible for TLTBI either because they were tuberculin skin test (TST) positive (121) or because their TST was negative/unknown but they were known contacts of a TB case or had impaired immunity (60). Of the patients eligible for TLTBI, 122 (67.4%) initiated TLTBI: 99 (81.1%) were treated with isoniazid for 6, 9 or 12 months; and 23 (18.9%) with short-course regimens including rifampin plus isoniazid and/or pyrazinamide. In total, 70 patients (57.4%) completed treatment, 39 (32.0%) defaulted, 7 (5.7%) interrupted treatment due to adverse effects, 2 developed TB, 2 died, and 2 moved away. Treatment completion was associated with having acquired HIV infection through heterosexual sex as compared to intravenous drug use (OR:4.6; 95% CI:1.4-14.7) and with having taken rifampin and pyrazinamide for 2 months as compared to isoniazid for 9 months (OR:8.3; 95% CI:2.7-24.9). CONCLUSIONS A minority of HIV-infected patients eligible for TLTBI actually starts and completes a course of treatment. Obstacles to successful implementation of this intervention need to be addressed.

Influence of physical activity and dietary habits on lipid profile, blood pressure and BMI in subjects with metabolic syndrome

BACKGROUND The present study was determined the influence of physical activity and dietary habits on lipid profile, blood pressure (BP) and body mass index (BMI) in subjects with metabolic syndrome (MS). AIMS Identify the relationship between physical activity and proper nutrition and the probability of suffering from myocardial infarction (MI). METHODS Hundred chronically ill with MS who were active and followed a healthy diet were classified as compliant, while the remaining subjects were classified as non-compliant. RESULTS The compliant subjects show lower BMI values (30.8±4.9 vs 32.5±4.6), as well as lower levels of triacylglycerol (130.4±48.2 vs 242.1±90.1), total cholesterol (193.5±39 vs 220.2±52.3) and low-density lipoprotein cholesterol (105.2±38.3 vs 139.2±45). They show higher values in terms of high-density lipoprotein cholesterol levels (62.2±20.1 vs 36.6±15.3), with statistically significant differences. In terms of both systolic and diastolic pressure, no differences were revealed between the groups; however, those who maintain proper dietary habits show lower systolic blood pressure levels than the inactive subjects. The probability of suffering from MI greatly increases among the group of non-compliant subjects. CONCLUSIONS Our results demonstrate how performing aerobic physical activity and following an individualized, Mediterranean diet significantly reduces MS indicators and the chances of suffering from MI.

Aider les étudiants en médecine à approcher la mort [Helping medical students to approach death].

A project recently launched by the Faculty of biology and medicine of Lausanne introduces the approach of facing death during both the dissection and the course of clinical activities. Existential questions relating to mortality are bound to arise sooner or later during the course of the study. For the sake of humanized clinical practice, these questions must be confronted. In response to a request by a student association, an accompanying curriculum with active student's contribution through encounters with death in anatomy and clinical situations was created in Lausanne. Students will benefit from this new program throughout their curriculum. This program is the first of its kind in Switzerland.

Adherence to interferon β-1b treatment in patients with multiple sclerosis in Spain

BACKGROUND Adherence to interferon β-1b (INFβ-1b) therapy is essential to maximize the beneficial effects of treatment in multiple sclerosis (MS). For that reason, the main objectives of this study are to assess adherence to INFβ-1b in patients suffering from MS in Spain, and to identify the factors responsible for adherence in routine clinical practice. METHODOLOGY/PRINCIPAL FINDINGS This was an observational, retrospective, cross-sectional study including 120 Spanish patients with MS under INFβ-1b treatment. Therapeutic adherence was assessed with Morisky-Green test and with the percentage of doses received. The proportion of adherent patients assessed by Morisky-Green test was 68.3%, being indicative of poor adherence. Nevertheless, the percentage of doses received, which was based on the number of injected medication, was 94.3%. The main reason for missing INFβ-1b injections was forgetting some of the administrations (64%). Therefore, interventions that diminish forgetfulness might have a positive effect in the proportion of adherent patients and in the percentage of doses received. In addition, age and comorbidities had a significant effect in the number of doses injected per month, and should be considered in the management of adherence in MS patients. CONCLUSION/SIGNIFICANCE Among all the available methods for assessing adherence, the overall consumption of the intended dose has to be considered when addressing adherence.

Existential values transformation in all organ transplantation: A qualitative prospective study.

Organ transplantation offers a treatment of choice for patients suffering from end stage illnesses. The aim of this IRB approved prospective qualitative study was to analyze patients’ psychological concerns from their inclusion on the waiting list for first organ transplantation (TX) (T1; N=71; kidney, K=30; liver, Li=11; lung, Lu=15; heart, H=15) and six months after TX (T2; N=49; K=15; Li=10; Lu=14; H=10). Semi-structured interviews were conducted at home or in a place selected by patients. Qualitative pattern analysis (QUAPA) of the verbatim transcriptions was applied. T1 (K) Patients maintained an apparent normality (87%), building emotional protection (23%), and developing a fatalist attitude towards life (43%). (Li) Physical limits were set to spare energy until TX (73%). Illness led to reevaluation of life values (66%). (Lu) Physical and psychological self-protection was prioritized when health declined (67%). Modified life values, fatalism (33%) and spirituality (27 %) were mentioned. (H) Patients husbanded physical (80%) and psychological (67%) resources and self-protection. Modified life values and fatalist attitude towards life were reported (40%). T2 (K) New perspective on life was described, with increase of empathy towards others (20%). (Li) Positive identity and life values modifications (60%), greater openness towards others, closeness to significant ones (30%) and a more self-centered attitude (30%) prioritizing the essential (20%) were reported. Lack of respect of life values generated anger (40%). (Lu) Setting existential priorities and increase in spirituality (64%), along with the development of new life values, greater openness to others (57%) and closeness to significant ones (21%) were underlined. Lack of respect of human values induced negative feelings (36%). Self-centered attitudes, setting limits to other people were mentioned (29%). (H) Change in life values with setting life priorities was reported (70%) with increase in spirituality, and the lack of respect of life values generated anger (50%). Self-centered attitudes were reported (60%). TX not only comes with positive physical benefits, but also with positive existential values and psychological transformation, and the development of a more altruistic attitude and humanistic values.

Factors associated with use of community mental health services by schizophrenia patients using multilevel analysis

BACKGROUND Persons with schizophrenia and related disorders may be particularly sensitive to a number of determinants of service use, including those related with illness, socio-demographic characteristics and organizational factors. The objective of this study is to identify factors associated with outpatient contacts at community mental health services of patients with schizophrenia or related disorders. METHODS This cross-sectional study analyzed 1097 patients. The main outcome measure was the total number of outpatient consultations during one year. Independent variables were related to socio-demographic, clinical and use of service factors. Data were collected from clinical records. RESULTS The multilevel linear regression model explained 46.35% of the variance. Patients with significantly more contacts with ambulatory services were not working and were receiving welfare benefits (p = 0.02), had no formal education (p = 0.02), had a global level of severity of two or three (four being the most severe) (p < 0.001), with one or more inpatient admissions (p < 0.001), and in contact with both types of professional (nurses and psychiatrists) (p < 0.001). The patients with the fewest ambulatory contacts were those with diagnoses of persistent delusional disorders (p = 0.04) and those who were attended by four of the 13 psychiatrists (p < 0.001). CONCLUSIONS As expected, the variables that explained the use of community service could be viewed as proxies for severity of illness. The most surprising finding, however, was that a group of four psychiatrists was also independently associated with use of ambulatory services by patients with schizophrenia or related disorders. More research is needed to carefully examine how professional support networks interact to affect use of mental health.

La question nationale en Europe du Sud-Est : genèse, émergence et développement de l'identité nationale albanaise au Kosovo et en Macédoine

NOTE METHODOLOGIQUE Avant d'entamer notre travail d'analyse, nous tenons à souligner d'emblée un certain nombre de remarques sur les obstacles affrontés et aux difficultés que nous avons rencontrées durant cette recherche. Plusieurs observations s'imposent quant aux concepts utilités, aux sources et travaux consultés et à la manière d'aborder la thématique nationale et nationaliste albanaise. Sachant que notre objectif a été de rompre avec le discours dominant sur le thème de l'identité nationale albanaise et de celui des travaux qui sont l'oeuvre, dans la plupart des cas, d'observateurs et d'acteurs à la fois, il fallait utiliser avec beaucoup de précaution les termes désignant aujourd'hui des groupes ethniques ou alors des entités territoriales contemporaines telles que le Kosovo ou la Macédoine. Pour la clarté de l'analyse, il était nécessaire d'utiliser certains concepts tels que l'ethnie, populations albanophones, albanaises ou proto-albanaises, toutefois, nous n'avons pas retenu le même sens que celui des acteurs. Lorsqu'on évoque ces populations, ce n'est pas le sens ethnique contemporain que nous retenons, mais celui qui pouvait prévaloir dans les contextes historiques auxquels nous nous sommes référés. Quant aux lieux et entités politiques d'aujourd'hui, nous avons choisi de recourir aux concepts tels qu'espace ou aire culturelle albanophone pour éviter de projeter dans le passé des catégories contemporaines comme le fait volontiers l'iconographie nationaliste. Enfin, par un souci d'impartialité, nous avons utilisé l'appellation des villes et des noms des figures historiques selon les contextes historiques abordés et avons précisé, entre parenthèses, l'appellation dans d'autres langues aussi. Concernant les sources et les travaux utilisés, comme nous venons de l'évoquer, la plupart d'eux sont émaillés par des considérations d'ordre idéologique et prennent clairement position soit en faveur de la position albanaise, soit de celle serbe, macédonienne ou autre. En fait, dans l'entreprise nationaliste, la définition d'un problème est un enjeu de luttes dans le temps et dans l'espace. Afin d'éviter de s'enliser dans le piège d'une lecture unilatérale des événements historiques, nous avons systématiquement utilisé des sources directes, croisé les sources d'information, sélectionné les publications utilisées selon leur rigueur scientifique et les références utilisées dans l'élaboration de leur argumentation. L'établissement d'une chronologie fiable a été une tâche difficile. En fait, comme nous l'avons rappelé dans notre introduction, peu d'ouvrages traitent de la question identitaire albanaise. En ce qui concerne la littérature albanaise, celle-ci est abondante, cependant, nous avons exclusivement utilisé des travaux universitaires qui ont le souci de la clarté et de l'objectivité et qui abordent la question albanaise sur la base des sources variées consultées (basées sur les archives officielles albanaise, serbe et internationale). Toutefois, nous avons d'une part relevé que certains travaux historiques utilisés ont été produits en Albanie durant la période du régime totalitaire d'Enver Hoxha. L'influence de ce régime dans la lecture de l'histoire ressort implicitement dans le choix des thèmes et des faits socio-historiques relatés par les auteurs. D'autre part, la littérature albanaise du Kosovo et de Macédoine et l'approche qu'elle effectue de la question nationale albanaise varie selon les contextes politiques. Ainsi, par exemple, les publications des années 1980 sur la Ligue de Prizren sont riches et fiables et poursuivent des objectifs autres que ceux visant à légitimer les revendications politiques albanaises. Quant aux travaux des auteurs serbes et macédoniens sur la question nationale albanaise, force est de constater qu'ils sont sous une forte influence nationaliste sur cette question. En fait, les travaux de Dimitrije Tucović, d'Aleksandar Matkovski et la publication dirigée par Nebojša Popov font exception à toute une production qui ne prend pas uniquement partie dans son jugement, mais qui a une attitude pour le moins problématique à l'égard des Albanais du Kosovo et de Macédoine. Compte tenu de ces constatations et de ces difficultés et afin de nous protéger des éventuelles approximations, nous avons systématiquement vérifié les faits socio-historiques relatés par la littérature historique occidentale qui portait sur Byzance, sur l'Empire ottoman ou alors sur la période plus contemporaine. Tout au long de notre recherche, nous avons privilégié certaines références des chercheurs (triés sur la base de leur connaissance de la question et des sources consultées) sur la région des Balkans pour l'établissement de notre chronologie (notamment ceux de Tahir Abdyli, de Skender Anamali, d'Ivo Banac, de Sadulla Brestovci, de Georges Castellan, d'Alain Ducellier, d'Ali Hadri, de Branko Horvat, de Kristo Frashëri, de Hivzi Islami, de Kristaq Prifti, de Noel Malcolm, d'Aleksandar Matkovski, de Pajazit Nushi, de Stefanaq Pollo, de Selami Pulaha, de Halim Purellku, de Skënder Rizaj, de Limon Rushiti, de Michel Roux, de Zija Shkodra, de Stavro Skendi de Dimitrije Tucović et de Miranda Vickers). Ces travaux nous ont été d'une grande utilité, même si les thématiques abordées étaient parfois complémentaires à notre objectif de recherche.

The use of palliative sedation: A comparison of attitudes of French-speaking physicians from Quebec and Switzerland.

OBJECTIVE: Previous literature has suggested that laws and regulations may impact the use of palliative sedation. Our present study compares the attitudes of French-speaking physicians practicing in the Quebec and Swiss environments, where different laws are in place regarding physician-assisted suicide. METHOD: Data were drawn from two prior studies, one by Blondeau and colleagues and another by Beauverd and coworkers, employing the same two-by-two experimental design with length of prognosis and type of suffering as independent variables. Both the effect of these variables and the effect of their interaction on Swiss and Quebec physicians' attitudes toward sedation were compared. The written comments of respondents were submitted to a qualitative content analysis and summarized in a comparative perspective. RESULTS: The analysis of variance showed that only the type of suffering had an effect on physicians' attitudes toward sedation. The results of the Wilcoxon test indicated that the attitudes of physicians from Quebec and Switzerland tended to be different for two vignettes: long-term prognosis with existential suffering (p = 0.0577) and short-term prognosis with physical suffering (p = 0.0914). In both cases, the Swiss physicians were less prone to palliative sedation. SIGNIFICANCE OF RESULTS: The attitudes of physicians from Quebec and Switzerland toward palliative sedation, particularly regarding prognosis and type of suffering, seem similar. However, the results suggest that physicians from Quebec could be slightly more open to palliative sedation, even though most were not in favor of this practice as an answer to end-of-life existential suffering.

Fortalezas y amenazas en torno a la seguridad del paciente según la opinión de los profesionales de enfermería

The aim of this research is to know the barriers and opportunities that nursing professionals detect in their clinical practice in order to develop the culture of patient safety and to identify future research lines. This qualitative study is based on the DELPHI method, with a group of 19 nursing professionals from education and care practice, involving both primary and specialized care. Weaknesses and threats revolve around five categories: profession, organization and infrastructure; indicators; communication and safety culture; and safety training. Opportunities to improve safety cover six categories: organizational change; promotion of the safety culture, professional training and development; relationship with the patients; research; and strategic planning. Work is needed to improve safety and nursing should be ready to assume this leadership.

Efficacy of two educational interventions about inhalation techniques in patients with chronic obstructive pulmonary disease (COPD). TECEPOC: study protocol for a partially randomized controlled trial (preference trial).

BACKGROUND Drugs for inhalation are the cornerstone of therapy in obstructive lung disease. We have observed that up to 75 % of patients do not perform a correct inhalation technique. The inability of patients to correctly use their inhaler device may be a direct consequence of insufficient or poor inhaler technique instruction. The objective of this study is to test the efficacy of two educational interventions to improve the inhalation techniques in patients with Chronic Obstructive Pulmonary Disease (COPD). METHODS This study uses both a multicenter patients´ preference trial and a comprehensive cohort design with 495 COPD-diagnosed patients selected by a non-probabilistic method of sampling from seven Primary Care Centers. The participants will be divided into two groups and five arms. The two groups are: 1) the patients´ preference group with two arms and 2) the randomized group with three arms. In the preference group, the two arms correspond to the two educational interventions (Intervention A and Intervention B) designed for this study. In the randomized group the three arms comprise: intervention A, intervention B and a control arm. Intervention A is written information (a leaflet describing the correct inhalation techniques). Intervention B is written information about inhalation techniques plus training by an instructor. Every patient in each group will be visited six times during the year of the study at health care center. DISCUSSION Our hypothesis is that the application of two educational interventions in patients with COPD who are treated with inhaled therapy will increase the number of patients who perform a correct inhalation technique by at least 25 %. We will evaluate the effectiveness of these interventions on patient inhalation technique improvement, considering that it will be adequate and feasible within the context of clinical practice.

Efficacy and safety of a multifactor intervention to improve therapeutic adherence in patients with chronic obstructive pulmonary disease (COPD): protocol for the ICEPOC study.

Low therapeutic adherence to medication is very common. Clinical effectiveness is related to dose rate and route of administration and so poor therapeutic adherence can reduce the clinical benefit of treatment. The therapeutic adherence of patients with chronic obstructive pulmonary disease (COPD) is extremely poor according to most studies. The research about COPD adherence has mainly focussed on quantifying its effect, and few studies have researched factors that affect non-adherence. Our study will evaluate the effectiveness of a multifactor intervention to improve the therapeutic adherence of COPD patients.