Internet information and medical consultations: experiences from patients' and physicians' perspectives

OBJECTIVE: Many patients use the Internet to obtain health-related information. It is assumed that health-related Internet information (HRII) will change the consultation practice of physicians. This article explores the strategies, benefits and difficulties from the patients' and physicians' perspective. METHODS: Semi-structured interviews were conducted independently with 32 patients and 20 physicians. Data collection, processing and analysis followed the core principles of Grounded Theory. RESULTS: Patients experienced difficulties in the interpretation of the personal relevance and the meaning of HRII. Therefore they relied on their physicians' interpretation and contextualisation of this information. Discussing patients' concerns and answering patients' questions were important elements of successful consultations with Internet-informed patients to achieve clarity, orientation and certainty. Discussing HRII with patients was appreciated by most of the physicians but misleading interpretations by patients and contrary views compared to physicians caused conflicts during consultations. CONCLUSION: HRII is a valuable source of knowledge for an increasing number of patients. Patients use the consultation to increase their understanding of health and illness. Determinants such as a patient-centred consultation and timely resources are decisive for a successful, empowering consultation with Internet-informed patients. PRACTICAL IMPLICATIONS: If HRII is routinely integrated in the anamnestic interview as a new source of knowledge, the Internet can be used as a link between physicians' expertise and patient knowledge. The critical appraisal of HRII during the consultation is becoming a new field of work for physicians.

Comment commencer l'entretien médical ? Réflexions sur la phase sociale à partir d'enregistrements vidéo [How do we begin a medical interview? Reflections from videotapes]

L'entrevue médicale est constituée de plusieurs étapes, chacune d'entre elles comprenant des tâches et des objectifs particuliers pour le médecin. La partie initiale de la consultation médicale, la phase sociale, constitue la première pierre dans la construction d'une relation médecin-patient de confiance et de qualité. Si, d'un point de vue structurel, la littérature a répondu de façon claire et concordante, des questions demeurent ouvertes d'un point de vue procédural. De quelle manière le médecin parvient-il à établir le premier contact ? Comment procède-t-il pour accueillir son patient ? Des pistes pour répondre à ces questions se repèrent dans le travail de révision des enregistrements vidéo des consultations de médecine générale qui sont régulièrement pratiqués à la Policlinique médicale universitaire (PMU) de Lausanne. [Auteurs] The medical interview consists of several steps, each consisting of specific tasks and objectives for the doctor. The initial step of the medical consultation, the social phase, is the cornerstone in the construction of a doctor-patient relationship of trust and quality. If, in a structural point of view, the literature has responded in a clear and consistent way, questions remain openned in a procedural point of view. How successful is the physician to establish the first contact? How does he proceed to welcome his patient? We looked out ways to address these issues by the work of revising the video recordings of general medical consultations, which are regularly practiced at the Medical outpatient clinic of the University of Lausanne.

Integrating sexuality into gynaecological consultations: gynaecologists' perspectives

There are currently few studies exploring doctors' personal perspectives on integrating sexuality into medical consultations. This study focuses on the views of gynaecologists on introducing, or not introducing, sexuality into their work. A total of 30 semistructured interviews were conducted with gynaecologists in the French-speaking part of Switzerland. The thematic content analysis and computer-assisted lexical analysis (Alceste) on the interview transcripts highlighted four categories: perceptions and description of sexuality, patient's sexological history, training in sexology and perceived difficulties. It is observed that, above all, the 'medical dimension' characterises gynaecologists' perceptions. Of greater interest is our observation of disparities in gynaecologists' discussion of their practice, which is often the product of lay knowledge based on common sense and/or personal experience. Finally, the decision to integrate questions relating to sexuality seems to depend on non-medical factors such as the personal experience, interest or gender of the doctor.

An exploration of the needs and goals of the health professional and patient in a medical consultation

This Study is the first phase of a three-phase study continuing over three years. Twent)' health professionals from different disciplinary backgrounds (medical doctors, nurses, allied health professionals) and 20 patients across a range of medical condidons, education, gender, and socio-economic backgrounds, pardcipated in one-on-one semi-structured interviews. Participants described their experiences and percepdons of both effecdve and sadsfying medical consultations and dissadsf)'ing and ineffecdve ones. They also discussed their individual goals and needs in the consultation process. Results indicated that while there were some similarides in consultation goals and needs between health professionals, there were also clear differences across the different discipUnes. In addition, there were clear differences in goals and needs across the twenty padents. These findings are discussed within the framework of communicadon accommodadon theor}' (CAT) and the linguisdc model of padent pardcipadon (LMOPP) and focus on understanding the different dynamics that underpin varying health professional and padent interacdons.

Avaliação da consulta médica realizada por ingressantes na residência de Pediatria

Diversos autores relatam que a consulta médica se associa a melhores resultados quando se adota como referencial o modelo centrado no paciente. OBJETIVO: Avaliar se os médicos ingressantes na residência de Pediatria realizam consultas ambulatoriais segundo pressupostos do modelo centrado no paciente. MÉTODO: Em 2007, no início de seu estágio de ambulatório, dez residentes foram selecionados aleatoriamente para serem filmados durante a realização de uma consulta. Adotando-se como referencial teórico pressupostos do modelo centrado no paciente, os dados foram analisados por meio de metodologia qualitativa, por meio da técnica exploratória, com três juízes independentes. RESULTADOS: A maioria dos residentes explora precocemente a primeira queixa referida pelos pais, assumindo-a como principal; não explora outras queixas; decide e faz orientações terapêuticas de modo não compartilhado; conversa pouco com as crianças; cria longos momentos de silêncio durante a consulta; não explica o exame físico e às vezes utiliza o prontuário como a principal fonte de informação. CONCLUSÃO: Os residentes realizam consultas sem a inclusão da perspectiva dos pais e, portanto, não atendem segundo pressupostos do modelo centrado no paciente.

Vidas arriscadas: uma reflexão sobre a relação entre o número de gestações e mortalidade materna

Este estudo teve por objetivo identificar o risco e os fatores associados à mortalidade materna de multigestas (cinco ou mais gestações). Descreve a tendência da Taxa de Fecundidade Total (TFT) e da Razão de Mortalidade Materna (RMM) de 1998 a 2004 no Paraná. Apresenta uma análise dos 822 óbitos maternos deste período, o cálculo da Razão de Mortalidade Materna Específica, o Risco Relativo, a freqüência e o Odds Ratio para algumas variáveis segundo número de gestações. Analisa também as causas e a evitabilidade dos óbitos maternos. Os resultados apontaram TFT baixa (1,8 filhos por mulher) e a RMM elevada (69,7/100.000 nascidos vivos) no Paraná em 2004. Um quarto dos 822 óbitos maternos (206) era de multigestas (cinco ou mais gestações), o risco relativo de morte materna foi seis vezes superior do que para as mulheres com até duas gestações, e os perfis sociodemográfico e o reprodutivo foram mais desfavoráveis para aquele grupo de mulheres. A baixa escolaridade, a idade igual ou acima de 30 anos e o pré-natal com menos de quatro consultas apresentaram associação com o maior número de gestações. A proporção de mortes por causas obstétricas indiretas, hemorragias e aborto, foi maior entre as multigestas, e cerca de 90% dos óbitos deste grupo foi considerado evitável. Concluiu-se que o monitoramento das multigestas com idade avançada e em desvantagem social, bem como ações efetivas de planejamento familiar, e serviços obstétricos qualificados para gestação de alto risco são medidas que podem contribuir para a redução da mortalidade materna

The burden of physical activity on type 2 diabetes public healthcare expenditures among adults: a retrospective study

Background: Determinants of public healthcare expenditures in type 2 diabetics are not well investigated in developing nations and, therefore, it is not clear if higher physical activity decreases healthcare costs. The purpose of this study was to analyze the relationship between physical activity and the expenditures in public healthcare on type 2 diabetes mellitus treatment. Methods: Cross-sectional study carried out in Brazil. A total of 121 type 2 diabetics attended to in two Basic Healthcare Units were evaluated. Public healthcare expenditures in the last year were estimated using a specific standard table. Also evaluated were: socio-demographic variables; chronological age; exogenous insulin use; smoking habits; fasting glucose test; diabetic neuropathy and anthropometric measures. Habitual physical activity was assessed by questionnaire. Results: Age (r = 0.20; p = 0.023), body mass index (r = 0.33; p = 0.001) and waist-to-hip ratio (r = 0.20; p = 0.025) were positively related to expenditures on medication for the treatment of diseases other than diabetes. Insulin use was associated with increased expenditures. Higher physical activity was associated with lower expenditure, provided medication for treatment of diseases other than diabetes (OR = 0.19; p = 0.007) and medical consultations (OR = 0.26; p = 0.029). Conclusions: Type 2 diabetics with higher enrollment in physical activity presented consistently lower healthcare expenditures for the public healthcare system.

Effects of Aerobic Training on Psychosocial Morbidity and Symptoms in Patients With Asthma A Randomized Clinical Trial

Background: Asthma symptoms reduce patients daily activities, impair their health-related quality of life (HRQoL), and increase their reports of anxiety and depress, all of which seem to be related to a decrease in asthma control. Aerobic exercise training is known to improve aerobic fitness and reduce dyspnea in asthmatics; however, its effect in reducing psychologic distress and symptoms remains poorly understood. We evaluated the role of an aerobic training program in improving HRQoL (primary aim) and reducing psychologic distress and asthma symptoms (secondary aims) for patients with moderate or severe persistent asthma. Methods: A total of 101 patients were randomly assigned to either a control group or an aerobic training group and studied during the period between medical consultations. Control group patients (educational program plus breathing exercises) (n = 51) and training group patients (educational program plus breathing exercises plus aerobic training) (n = 50) were followed twice a week during a 3-month period. HRQoL and levels of anxiety and depression were quantified before and after treatment. Asthma symptoms were evaluated monthly. Results: At 3 months, the domains (physical limitations, frequency of symptoms, and psychosocial) and total scores of HRQoL, significantly improved only in the training group patients (P < .001); the number of asthma-symptom-free days and anxiety and depression levels also significantly improved in this group (P < .001). In addition, a linear relationship between improvement in aerobic capacity and the days without asthma symptoms was observed (r = 0.47; P < .01). Conclusions: Our results suggest that aerobic training can play an important role in the clinical management of patients with persistent asthma. Further, they may be especially useful for patients with higher degrees of psychosocial distress.

Effects of Aerobic Training on Airway Inflammation in Asthmatic Patients

MENDES, F. A. R., F. M. ALMEIDA, A. CUKIER, R. STELMACH, W. JACOB-FILHO, M. A. MARTINS, and C. R. F. CARVALHO. Effects of Aerobic Training on Airway Inflammation in Asthmatic Patients. Med. Sci. Sports Exerc., Vol. 43, No. 2, pp. 197-203, 2011. Purpose: There is evidence suggesting that physical activity has anti-inflammatory effects in many chronic diseases; however, the role of exercise in airway inflammation in asthma is poorly understood. We aimed to evaluate the effects of an aerobic training program on eosinophil inflammation (primary aim) and nitric oxide (secondary aim) in patients with moderate or severe persistent asthma. Methods: Sixty-eight patients randomly assigned to either control (CG) or aerobic training (TG) groups were studied during the period between medical consultations. Patients in the CG (educational program + breathing exercises; N = 34) and TG (educational program + breathing exercises + aerobic training; N = 34) were examined twice a week during a 3-month period. Before and after the intervention, patients underwent induced sputum, fractional exhaled nitric oxide (FeNO), pulmonary function, and cardiopulmonary exercise testing. Asthma symptom-free days were quantified monthly, and asthma exacerbation was monitored during 3 months of intervention. Results: At 3 months, decreases in the total and eosinophil cell counts in induced sputum (P = 0.004) and in the levels of FeNO (P = 0.009) were observed after intervention only in the TG. The number of asthma symptom-free days and (V) over dotO(2max) also significantly improved (P < 0.001), and lower asthma exacerbation occurred in the TG (P < 0.01). In addition, the TG presented a strong positive relationship between baseline FeNO and eosinophil counts as well as their improvement after training (r = 0.77 and r = 0.9, respectively). Conclusions: Aerobic training reduces sputum eosinophil and FeNO in patients with moderate or severe asthma, and these benefits were more significant in subjects with higher levels of inflammation. These results suggest that aerobic training might be useful as an adjuvant therapy in asthmatic patients under optimized medical treatment.

Hospitalization of older adults due to ambulatory care sensitive conditions

OBJECTIVE To analyze the temporal evolution of the hospitalization of older adults due to ambulatory care sensitive conditions according to their structure, magnitude and causes. METHODS Cross-sectional study based on data from the Hospital Information System of the Brazilian Unified Health System and from the Primary Care Information System, referring to people aged 60 to 74 years living in the state of Rio de Janeiro, Souhteastern Brazil. The proportion and rate of hospitalizations due to ambulatory care sensitive conditions were calculated, both the global rate and, according to diagnoses, the most prevalent ones. The coverage of the Family Health Strategy and the number of medical consultations attended by older adults in primary care were estimated. To analyze the indicators’ impact on hospitalizations, a linear correlation test was used. RESULTS We found an intense reduction in hospitalizations due to ambulatory care sensitive conditions for all causes and age groups. Heart failure, cerebrovascular diseases and chronic obstructive pulmonary diseases concentrated 50.0% of the hospitalizations. Adults older than 69 years had a higher risk of hospitalization due to one of these causes. We observed a higher risk of hospitalization among men. A negative correlation was found between the hospitalizations and the indicators of access to primary care. CONCLUSIONS Primary healthcare in the state of Rio de Janeiro has been significantly impacting the hospital morbidity of the older population. Studies of hospitalizations due to ambulatory care sensitive conditions can aid the identification of the main causes that are sensitive to the intervention of the health services, in order to indicate which actions are more effective to reduce hospitalizations and to increase the population’s quality of life.

Trends in the use of antidepressants among older adults: Bambuí Project

OBJECTIVE To analyze the trends and factors associated with the antidepressant use among older adults. METHODS This population-based study evaluated older adults in 1997 (n = 351, baseline) and the survivors at the 15th follow-up year (n = 462, in 2012) among the aging cohort of Bambuí. The prevalence of antidepressant use was estimated, and the most commonly used antidepressants each year were identified. Prevalence ratios with 95% confidence intervals were estimated using Poisson regression with robust variance to investigate differences in the prevalence of use between 1997 and 2012. RESULTS The overall consumption of antidepressants (PR = 2.87, 95%CI 1.94;4.25) and of selective serotonin reuptake inhibitors (PR = 7.50, 95%CI 3.74;15.02) was significantly higher in 2012. However, no significant difference was observed in the use of tricyclic antidepressants between the two cohorts (PR = 0.89, 95%CI 0.49;1.62). In the 2012 cohort, antidepressant use was associated with females, increased age, increased income (≥ 4 minimum wages), self-assessment of health as reasonable, and attending ≥ 5 medical consultations in the last 12 months. CONCLUSIONS The increased consumption of antidepressants in the period due to increased use of selective serotonin reuptake inhibitors was consistent with results observed in international studies of different population groups and contexts. The positive correlation observed between antidepressant use and family income may be a warning of possible inequalities in access to mental health services.

Adolescents and School Asthma Knowledge and Attitudes

Introduction: bronchial asthma is a chronic disease that affects a high percentage of adolescents, with a significant restriction of daily activities, and is a cause of school absenteeism. The relationships between adolescents and asthma disease in school were assessed, with a view to improving knowledge about the asthmatic adolescent. Methods: a survey was conducted in the Lisbon metropolitan area, covering urban (Lisbon) and rural (Lourinh˜a ) zones and including 1879 students and 81 teachers from the 7th to 9th high school years. The study groups were asthmatic students, their peers, and teachers. A self-administered questionnaire was applied to collect information. The results were compared with a reference group of 91 asthmatic students attending our Department of Immunoallergy-Hospital Dona Estefânia. Cotinine urinary measurements were made in a sample of asthmatics and a control group. Results: the prevalence of current asthma among students was 10%. Estimates of asthma annual burden among 7th to 9th year students from Lisbon and Lourinh˜a high schools included 4,307 days missed from school, 4,148 medical consultations and a minimum of 351 hospital emergency care and 80 hospital admissions. Exposure to passive smoking was not significantly different between asthmatic students and theirs peers. Cotinine urinary measurements did not discriminate between exposed and non-exposed individuals. Cigarette smoking was almost as common among adolescent asthmatics (5.4%) as it was in non-asthmatic subjects (6.7%). However, 55% of asthmatics mentioned active and passive smoking as an asthma exacerbating factor. Asthmatic students, theirs peers and teachers showed a deficient knowledge about asthma (mean group scores: 17.6; 14.2 and 17.7 of a possible 30), particularly in the areas related to asthma recognition and its management. Asthmatics attending our Allergy Department had the highest scores. All groups showed tolerance in the sense of a positive and understanding attitude toward a person with asthma. However, traditional beliefs about asthma disease (dependence, inferiority...) were confirmed. A positive correlation between knowledge levels and tolerance attitudes was found. Conclusion: in view of the dimension of the asthma problem in adolescence and its social and economic impact, it is justifiable to assess the need for the implementation of asthma education programs in schools in order to improve asthma management by the adolescents and their schools.

Caraterização do acesso ao Centro Hospitalar Lisboa Norte, EPE : análise do acesso e da utilização da consulta externa e da urgência do Centro Hospitalar Lisboa Norte, EPE

RESUMO - Introdução: As alterações verificadas no dimensionamento e na redistribuição da rede de prestação de cuidados hospitalares, nomeadamente no que confere à reorganização das áreas de influência, e, cumulativamente, à abertura do Hospital Beatriz Ângelo, tornam evidente a necessidade de se analisar o acesso e a utilização da consulta externa e da urgência, antes e depois destas alterações. Objetivo: Este trabalho de investigação tem como principal objetivo analisar o acesso e a utilização da consulta externa e da urgência do Centro Hospitalar Lisboa Norte e verificar a evolução desse mesmo acesso, no período de 2010 a 2013. Material e Métodos: Estudo descritivo que visa determinar a frequência e a distribuição dos episódios de Consulta Externa e de Urgência do Centro Hospitalar Lisboa Norte. Foram considerados todos os episódios de consulta externa (3785579 episódios) e de urgência (1140052 episódios) ocorridos entre 1 de janeiro de 2010 e 31 de dezembro de 2013. Resultados: Entre 2010 e 2013, verificou-se o aumento de +2,3% no número de primeiras consultas e de +5%, em consultas subsequentes. As especialidades médicas com maior afluência são Oftalmologia, Dermatologia I, Pediatria e Otorrinolaringologia I. Observou-se, no total de consultas, qual a percentagem que, em cada ano, obteve um tempo de espera inferior a 1 mês, entre a marcação e a realização da consulta: 56,7%, em 2010; 54,3%, em 2011; 55% em 2012; 56,2%, em 2013. Verificou-se o decréscimo do número de atendimentos de urgência, no período em análise, de -38,9%. Cerca de 90% dos atendimentos de urgência respeitam a utentes que acorrem diretamente à urgência sem virem referenciados de outras unidades de saúde. Os meses de janeiro e fevereiro são aqueles que registam maior afluência, 9,9% e 8,8%, respetivamente. O período de maior afluência regista-se entre as 9 e as 11 horas, representando 20,7% dos episódios, em 2010, 21,2%, em 2011, 21% e 20,5%, em 2012 e 2013, respetivamente. Conclusão: Face à alteração da área de influência do Centro Hospitalar Lisboa Norte, torna-se necessária a adaptação da capacidade instalada para haja um sobredimensionamento face à procura, bem como a adequação de recursos internos, financeiros, humanos e tecnológicos.

The influence of patient's consciousness regarding high blood pressure and patient's attitude in face of disease controlling medicine intake

OBJECTIVE: To assess the relation between blood pressure control and the following: the Morisky-Green test, the patient's consciousness regarding high blood pressure, the patient's attitude in face of medicine intake, the patient's attendance at medical consultations, and the subjective physician's judgment. METHODS: We studied 130 hypertensive patients with the following characteristics: 73% females, 60±11 years, 58% married, 70% white, 45% retired, 45% with incomplete elementary schooling, 64% had a familial income of 1 to 3 minimum wages, body mass index of 30±7 kg/m², consciousness regarding the disease for a mean period of 11±9.5 years, and mean treatment duration of 8 ±7 years. RESULTS: Only 35% of the hypertensive individuals had blood pressure under control and a longer duration of treatment (10±7 vs 7±6.5 years; P<0.05). The retiree predominated. The result of the Morisky-Green test did not relate to blood pressure control. In evaluating the attitude in face of medicine intake, the controlled patients achieved significantly higher scores than did the noncontrolled patients (8±1.9 vs 7 ±2, P<0.05). The hypertensive patients had higher levels of consciousness regarding their disease and its treatment, and most (70%) patients attended 3 or 4 medical consultations, which did not influence blood pressure control. The physicians attributed significantly higher scores regarding adherence to treatment to controlled patients (6±0.8 vs 5±1.2; P<0.05). CONCLUSION: Consciousness regarding the disease, the Morisky-Green test, and attendance to medical consultations did not influence blood pressure control.

Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care.

BACKGROUND In the last decades the presence of social inequalities in diabetes care has been observed in multiple countries, including Spain. These inequalities have been at least partially attributed to differences in diabetes self-management behaviours. Communication problems during medical consultations occur more frequently to patients with a lower educational level. The purpose of this cluster randomized trial is to determine whether an intervention implemented in a General Surgery, based in improving patient-provider communication, results in a better diabetes self-management in patients with lower educational level. A secondary objective is to assess whether telephone reinforcement enhances the effect of such intervention. We report the design and implementation of this on-going study. METHODS/DESIGN The study is being conducted in a General Practice located in a deprived neighbourhood of Granada, Spain. Diabetic patients 18 years old or older with a low educational level and inadequate glycaemic control (HbA1c > 7%) were recruited. General Practitioners (GPs) were randomised to three groups: intervention A, intervention B and control group. GPs allocated to intervention groups A and B received training in communication skills and are providing graphic feedback about glycosylated haemoglobin levels. Patients whose GPs were allocated to group B are additionally receiving telephone reinforcement whereas patients from the control group are receiving usual care. The described interventions are being conducted during 7 consecutive medical visits which are scheduled every three months. The main outcome measure will be HbA1c; blood pressure, lipidemia, body mass index and waist circumference will be considered as secondary outcome measures. Statistical analysis to evaluate the effectiveness of the interventions will include multilevel regression analysis with three hierarchical levels: medical visit level, patient level and GP level. DISCUSSION The results of this study will provide new knowledge about possible strategies to promote a better diabetes self-management in a particularly vulnerable group. If effective, this low cost intervention will have the potential to be easily incorporated into routine clinical practice, contributing to decrease health inequalities in diabetic patients. TRIAL REGISTRATION Clinical Trials U.S. National Institutes of Health, NCT01849731.