Healthcare System-related Factors Research Articles

(P2-64) Pattern and Factors Associated with Violent Incidents in the Emergency Department of a Level-1 Trauma Center

BackgroundViolent incidents (VI) in emergency departments (EDs) are under-reported concerns for emergency care providers (ECP). There are limited data from EDs in India.ObjectiveThis is a study of pattern and factors associated with VIs in the ED of a Level-1 Trauma Center.MethodsA qualitative survey questionnaire was distributed to 42 ECPs who worked in the ED of the All India Institute of Medical Sciences. Responses of ECPs were compiled and analyzed.ResultsA total of 78.6% of nurses, 19.1% doctors, and 2.4% registration clerks participated in the study. A total of 54.8% were female. A total of 85.7% had five years of work experience in the ED. A total of 59.5% witnessed and experienced verbal abuse; 19.04% witnessed and experienced physical abuse. The remaining experienced and witnessed verbal abuse as well as physical abuse. A total of 57.1% had experienced VI multiple times in last six months. Of these, 88.2% faced the incident between 8 pm and 8 am. The ECP reported the incident to hospital authority's 54.8% of the time, 19.1% reported it to the police, and 14.29% did not report, while 7.1% reported to police and hospital administration. Eighty-five percent experienced insecurity & emotional disturbance. Patient-related factors included intoxication and anxiety. Healthcare system-related factors included delay in investigations, non-availability of beds, overcrowding of ED, and lack of staff. A total of 47.7% of participants felt that there was improper communication between healthcare workers and 40.1% felt that non-availability of senior doctor were the system deficiency factors. A total of 16.6% of ECPs had formal training regarding communication skills, and 11.9% had grief counseling. All respondents felt that steps should be taken to decrease and mitigate the VIs in the ED.ConclusionsVerbal and physical abuse of emergency care workers is common.

Adherence to Oral Chemotherapy in Childhood Acute Lymphoblastic Leukemia: An Evolutionary Concept Analysis

To clarify the concept of adherence to daily oral chemotherapy in children with acute lymphoblastic leukemia (ALL), to examine its implications for clinical practice, and to provide a foundation for further research and knowledge development. Published literature identified through the MEDLINE®, CINAHL®, PsycINFO, and ERIC databases. Identified attributes of adherence to oral chemotherapy in childhood ALL included motivation, persistence, collaboration, mindfulness, cognitive capacity, flexibility, active participation, and identification of key participants in the process. Identified antecedents included a diagnosis of leukemia, the perceived value of adherence, and patient, family, and healthcare system-related factors. Identified consequences included the potential for maintaining optimal drug levels and improving disease outcome, as well as increased patient and caregiver esteem through active participation in the process. Adherence in the context of childhood ALL is defined as the active self-care behavior of taking (or having the responsibility for administering) daily oral chemotherapy, in collaboration with and according to the instructions of the healthcare provider over a defined, prolonged treatment period. Adherence to oral chemotherapy in childhood ALL is a complex, multidimensional behavior that involves not only a willingness to follow the prescribed regimen over a prolonged period, but also the cognitive capacity and psychomotor skills to carry out the process. Nurses should recognize the importance of clear communication of medication instructions, reinforcement of adherence-related behaviors, and assistance with common issues such as pill-swallowing skills and reminder systems in caring for children with ALL.

Non-adherence in patients on chronic hemodialysis: an international comparison study

Adherence to diet and fluid restrictions by adults on hemodialysis treatment is challenging. This study compared non-adherence (NA) to diet and fluid restrictions between adult US and German hemodialysis patients, and assessed potential predictors for NA. A cross-sectional multicenter comparative study of 456 adult hemodialysis patients was conducted in 12 outpatient-based hemodialysis centers in the United States and Germany. NA was based on self-report using the Dialysis Diet and Fluid Non-adherence Questionnaire (DDFQ). Laboratory marker, interdialytic weight gain (IDWG) and dialysis adequacy (Kt/V) information were obtained from medical records. Mean time on dialysis was 50 months (range 3-336); mean age was 62 years (range 19-91), with the majority of patients (89.7%) being white. Self-reported frequency of NA to diet was 80.4% and to fluid 75.3% in the total sample. The degree of NA to diet and fluid differed significantly, with the US patients (68.1% vs. 61.1%) reporting less NA when compared with German (81.6% vs. 79.0%) patients (p<0.0001). Phosphorus, albumin, IDWG and Kt/V levels were higher in the US compared with the German subsample (all p<0.0001; IDWG p<0.003). Generalized regression models revealed that education (p<0.01) and smoking (p<0.01) predicted NA to diet, whereas single marital status (p<0.008) and male sex (p<0.04) were independent predictors for NA to fluid. NA persists as one of the most challenging tasks in health care of patients with chronic conditions, including hemodialysis patients. Our findings suggest that patient, condition-related, socioeconomic and health care system-related factors may contribute to NA to diet and fluid restrictions.

Determinants of medication underuse and medication overuse in patients with chronic non-malignant pain: A multicenter study

Background In chronic non-malignant pain, medication is often used as an important cornerstone of the treatment. Medication non-adherence is a frequent problem in chronic conditions. In patients with chronic non-malignant pain, medication non-adherence ranges between 8% and 53%. Two types of non-adherence can be identified: underuse and overuse of pain medication. Objective To examine determinants of both medication underuse and overuse non-adherence in patients with chronic non-malignant pain, with a focus on factors related to all five categories of determinants of medication non-adherence simultaneously, as proposed by the WHO. Design A multicenter cross-sectional study. Settings Three multidisciplinary outpatient pain centers in Flanders, Belgium. Participants A total of 265 patients with chronic non-malignant pain participated in the study. Methods Medication non-adherence was assessed by a self-report interview. Associations of socio-economic, treatment related, condition related, patient related and health care system related factors with medication underuse or overuse were determined by building two separate multivariable binary logistic regression models. Results Thirty eight percent of the patients were fully adherent. Based on multivariable analyses, underuse was significantly associated with more prescribed analgesics (OR = 2.303), self-medication (OR = 4.679), lower pain intensity (OR = 0.821), active coping strategies (OR = 1.132) and lack of information (OR = 0.268). Overuse of medication was associated with more prescribed analgesics (OR = 1.645) and current smoking (OR = 2.744). Conclusion Patients underusing or overusing their medication do have a different risk profile. The set of determinants of non-adherence, proposed by WHO, is suitable to study determinants of underuse, but the framework is less suitable to study determinants of medication overuse.

Factors Associated With Poor Medication Adherence In Hypertensive Patients In Lusaka, Zambia

Objectives: To determine the prevalence of drug adherence and factors associated with poor adherence to antihypertensive treatment among adults seen in the department of medicine at UTH. To investigate patient related and health care system related factors associated with poor adherence to antihypertensive Drugs. Methods: 237 adult patients aged 18 and above with previous diagnosis of essential hypertension receiving out patient care in the University Teaching Hospital (UTH) were recruited from the first week of November to the second week of December 2010. Information was collected regarding health care system related factors and care giver related factors to patient non adherence using self report and modified Hill-Bone compliance scale. Results: The prevalence of adherence was 83% by self report and 70% using modified Hill-Bone scale. The mean age was 57.8 ± 12.0 SD. Patients on three antihypertensive drugs were less likely to be nonadherent (OR 0.21; 95% 95% CI 0.06-0.79) than patients taking only one drug. Majority (60%) of the patients were reviewed at least twice in the last 6 months at the time of the interview. 195 (83%) patients reported that drugs prescribed were not available at the hospital pharmacy, but 186 (79%) of these were able to purchase the drugs elsewhere. Patients counseled by the nurse were more likely to be adherent than those not counseled by the nurse (OR 2.7: 95% CI1.0-7.3). Those who were counseled for more than 5 minutes had three fold likelihood of less non-adherence as reported by both self report and modified Hill-Bone with OR 0.3: 95% CI 0.2-0.8 and 0.3: 95% CI 0.1-0.5, respectively. Multivariable analysis showed that; participants were more likely to be non-adherent by self-report if they had attained a primary level of education, had missed appointments due to lack of transport, or had experienced the side effect of dizziness. Patients with heart failure were more likely to be nonadherent based on the modified Hill-Bone score. Conclusion: The prevalence of adherence among hypertensive patients was found to be higher than anticipated. The factors associated with nonadherence included side effect of dizziness, missed appointment due to lack of transport, and living at a distance of more than 10 km from the hospital. Taking 3 BP drugs and receiving more than 5 minutes of counseling about how to take medications were both associated with decreased likelihood of non-adherence.

Unplanned revisits to the emergency department: What emergency department nurses can do?

The purpose of this paper is to systemically review the literature associated with unplanned emergency department (ED) revisits and provide a comprehensive approach for ED nurses. Studies identified that factors related to the unplanned revisits rate in the ED included patient-related factors and illness-related and healthcare system-related factors. Inadequate preparation for patients’ discharge from the ED was one of the problems identified from the studies. It was suggested that the problem needs to be improved. There is a necessity to develop a model of discharge planning for ED discharge patients and ED nurses need to provide individual, effective discharge planning before discharge. Telephone follow-up after discharge also needs to be included. This can not only help in the early detection of the potential problems which patients may have after returning home, it also can enhance the knowledge and skills they need after discharge from the ED. When the unplanned ED revisits rate decreases, it may help to decrease the number of ED patients visit overall, improve the problem of ED overcrowding, decrease the workload of ED staff, decrease the cost of health care, provide better quality patient care, and improve patient satisfaction in the ED.

Season of diagnosis and prognosis in breast and prostate cancer

Patients with breast or prostate cancer diagnosed during the summer season have been observed to have better survival. The extent to which this is due to biological and/or health care system related factors is unclear. Using the Swedish Cancer Register and clinical databases, we analyzed overall survival by month of diagnosis among the incident cases of breast (n = 89,630) cancer and prostate (n = 72,375) cancer diagnosed from 1960 to 2004. We retrieved data on tumor stage from 1976 for breast cancer and 1997 for prostate cancer. Cox proportional hazards models were used to calculate relative risk of survival by the season of diagnosis. There was a higher hazard ratio of death in men and women diagnosed with cancer in the summer with a relative hazard of 1.20 (95% confidence interval 1.15-1.25) for July for prostate cancer and 1.14 (95% confidence interval 1.09-1.19) for August for breast cancer when compared to being diagnosed in January. This difference coincided with a lower mean number of cases diagnosed per day, and a higher proportion of advanced cases diagnosed in the summer. This pattern of presentation was stronger in the later years. The difference in stage distribution explains the seasonal variation in prognosis seen in this study. The variation may be because of structure of the health care system and a strong tradition of vacationing from mid June to mid August. Thus, the health care infrastructure and the late presentation of symptomatic disease may influence cancer survival studied by season of diagnosis substantially.

Factors Associated With Hospital Length of Stay and Hospital Charges of Motor Vehicle Crash–Related Hospitalizations Among Children in the United States

To calculate national estimates of motor vehicle crash (MVC)-related hospitalization and associated use of health care resources among patients 20 years and younger and to explore the effects of certain sociodemographic and health care system-related factors and injury severity on use of hospital resources and lengths of stay (LOSs) in the United States. Data from the 2003 Healthcare Cost and Utilization Project Kids' Inpatient Database were used. Pediatric inpatient care in 3438 hospitals in 36 US states. Patients Patients 20 years and younger hospitalized with MVC-related injuries. National estimates of MVC-associated hospitalizations, rates, resource use, Injury Severity Scores, and demographics were calculated. Potentially significant covariate associations were studied using hospital charges and LOS. Sixty-two thousand eight hundred eighty MVC-related hospitalizations occurred among patients 20 years and younger in the United States in 2003, resulting in more than $2.0 billion (SD = $1.2 million) in inpatient charges and 304 196 days (SD = 55,113 days) of hospitalization. Mean (SD) hospital charges and LOS were $33,440 ($55,113) and 4.8 (7.7) days, respectively. The mean (SD) Injury Severity Score was 10.3 (11.4). Adolescents aged 18 through 20 years had the highest hospitalization rates (197 cases per 100,000 children). Older age, being male, urban hospital location, mortality during hospitalization, higher injury severity, and longer LOS were significantly associated with higher total charges. Longer LOS was significantly associated with older age, urban hospital location, higher injury severity, and mortality. Motor vehicle crash-related injuries among children burden health care resources, with nationwide charges exceeding $2 billion annually.

Family doctors’ assessment of patient- and health care system-related factors contributing to non-adherence to diabetes mellitus guidelines

The aim of this study was to assess family doctors' opinions on the patient- and health care system-related factors contributing to non-adherence to diabetes mellitus clinical practice guidelines (CPG) in Estonia. Descriptive postal survey using a self-administered questionnaire. Of the 354 doctors who received the questionnaire 46% (n=163) responded. Seventy-six percent of them have type 2 diabetes guidelines. Low awareness of diabetes and its complications as well as patients' low motivation to change their lifestyle were considered to be the biggest difficulties in managing individual patients. In addition to the most often listed problems non-compliance with medical regimen, patients' financial problems and their nonattendance were mentioned. The greatest health care system-related barriers to practices providing desirable care were the lack of special diabetes education for nurses and underfunding, and an inadequate number of patients' educational materials. The patient-related issues were regarded as problems in 96% of the cases and health care system-related factors were mentioned in 79% of the cases. Family doctors in Estonia consider patient-related factors to be key issues in non-adherence to diabetes mellitus clinical practice guidelines.

Adherence in antiretroviral therapy: a review of qualitative studies

Adherence in antiretroviral therapy: a review of qualitative studies

Regional variation in incidence of primary total hip arthroplasties and revisions in Denmark, 1996–2002

Background We examined incidence rates (IR) of total hip arthroplasty (THA) in Denmark according to county and type of hospital, and investigated possible factors associated with any variations.Methods Through the Danish Hip Arthroplasty Registry, we identified all cases of primary THAs (n = 37,144) and revisions (n = 6,446) between 1996 and 2002. Unadjusted and age- and gender-standardized, hospital type- and county-specific IRs were calculated. Using multiple regression analysis, we examined possible factors associated with the variations.Results Over the study period, age- and sex-standardized IRs of primary THAs for university and other hospitals increased by 10% and 40%, respectively. IRs of revisions increased for other hospitals by 33%, but decreased for university hospitals by 30%. Unadjusted IRs varied among counties (n = 15), which remained despite age- and gender-standardization. The IR ratio was 1.4 (95% CI: 1.3–1.6) when comparing the counties with the highest and lowest IRs. No association was found between IRs of THA and the number of orthopedic surgeons per 100,000 inhabitants, proportion of patients with primary arthrosis, preoperative Harris Hip Score, hospital costs, the counties’Gross Domestic Product, or population density.Interpretation Substantial regional differences in the IRs of THA procedures were found. We found no associations between IRs and a range of patient- and healthcare system-related factors. ▪

Adoption of new technologies for early detection of melanoma in dermatologic practice

The identification and diagnosis of early melanoma will reduce unnecessary operations and may be important in reducing mortality from melanoma and impacting cost savings to the health system. New technologies are being developed and used at some specialized centers to facilitate the detection and diagnosis of early melanoma for patients at high risk. These technologies include but are not limited to digital photography, dermoscopy, computerized image analysis systems, and confocal scanning laser microscopy. To most effectively implement these novel approaches, it is important to identify the key factors that influence the adoption or diffusion of new medical technologies. We propose patient-, physician-, and health care system–related factors that influence the diffusion of new technologies for the early detection of skin cancer. Studies involving physicians and patients in a variety of clinical settings need to be conducted to achieve a greater understanding of the barriers to the adoption of these new technologic tools that are intended to aid in skin cancer screening.

Receipt of Asthma Subspecialty Care by Children in a Managed Care Organization

Although proper outpatient asthma management sometimes requires care from subspecialists, there is little information on factors affecting receipt of subspecialty care in a managed care setting. To determine factors associated with receipt of subspecialty care for children with asthma in a managed care organization. We conducted an analysis of the claims from 3163 children with asthma enrolled in a university-based managed care organization from January 1998 to October 2000. We used logistic regression analysis to determine factors associated with an outpatient asthma visit with an allergist or pulmonologist. Of the 3163 patients, 443 (14%) had at least 1 subspecialist visit for asthma; 354 (80%) were seen by an allergist, 63 (14%) were seen by a pulmonologist, and 26 (6%) were seen by both. In multivariate analysis, patients with more severe asthma (odds ratio [OR], 3.81; 95% confidence interval [CI], 2.99-4.86) and older patients (OR, 1.04; 95% CI, 1.02-1.07) were more likely to receive care from a subspecialist. Compared with Medicaid patients, both non-Medicaid patients with copayment (OR, 2.52; 95% CI, 1.85-4.43) and non-Medicaid patients without any copayment (OR, 3.40; 95% CI, 2.35-4.93) were more likely to receive care from an asthma subspecialist. Children insured by Medicaid are less likely to receive care from subspecialists for asthma. Reasons may be due to health care system-related factors, such as accessibility of subspecialists, to physician referral decisions, and/or to patient factors, such as adherence to recommendations to see a subspecialist. Our findings suggest a need to further investigate health care system barriers, physician referral, and patient acceptance and completion of subspecialty referral.