Provider-related Factors Research Articles

Healthcare disparities among orthopedic trauma patients in the USA: socio-demographic factors influence the management of calcaneus fractures

BackgroundSocio-demographic factors have been suggested to contribute to differences in healthcare utilization for several elective orthopedic procedures. Reports on disparities in utilization of orthopedic trauma procedures remain limited. The purpose of our study is to assess the roles of clinical and socio-demographic variables in utilization of operative fixation of calcaneus fractures in the USA.MethodsThe National Inpatient Sample (NIS) dataset was used to analyze all patients from 2005 to 2014 with closed calcaneal fractures. Multivariate logistic regression analyses were performed to evaluate the impact of clinical and socio-demographic variables on the utilization of surgical versus non-surgical treatment.ResultsA total of 17,156 patients with closed calcaneus fractures were identified. Operative treatment was rendered in 7039 patients (41.03%). A multivariate logistic regression demonstrated multiple clinical and socio-demographic factors to significantly influence the utilization of surgical treatment including age, gender, insurance status, race/ethnicity, income, diabetes, peripheral vascular disease, psychosis, drug abuse, and alcohol abuse (p < 0.05). In addition, hospital size and hospital type (teaching versus non-teaching) showed a statistically significant difference (p < 0.05).ConclusionsBesides different clinical variables, we identified several socio-demographic factors influencing the utilization of surgical treatment of calcaneus fractures in the US patient population. Further studies need to identify the specific patient-related, provider-related, and system-related factors leading to these disparities.

Medication adherence for persons with spinal cord injury and dysfunction from the perspectives of healthcare providers: A qualitative study

Context: People with spinal cord injury and dysfunction (SCI/D) often take multiple medications (i.e. polypharmacy) to manage secondary health complications and multiple chronic conditions. Numerous healthcare providers are often involved in clinical care, increasing the risk of fragmented care, problematic polypharmacy, and conflicting health advice. These providers can play a crucial role in assisting patients with medication self-management to improve medication adherence.Design: A qualitative study involving telephone interviews, following a semi-structured guide that explored healthcare providers' conceptualization of factors impacting medication adherence for persons with SCI/D. The interviews were transcribed and analyzed descriptively and interpretively using a constant comparative process with the assistance of data display matrices. Analysis was guided by an ecological model of medication adherence.Setting and participants: Thirty-two healthcare providers from Canada, with varying clinical expertise.Intervention: Not Applicable.Outcome measures: Not Applicable.Results: Providers identified several factors that impact medication adherence for persons with SCI/D, which were grouped into micro (medication and patient-related), meso- (provider-related) and macro- (health system-related) factors. Medication-related factors included side effects, effectiveness, safety, and regimen complexity. Patient-specific factors included medication knowledge, preferences/expectations/goals, severity and type of injury, cognitive function/mental health, time since injury, and caregiver support. Provider-related factors included knowledge/confidence and trust. Health system-related factors included access to healthcare and access to medications. While providers were able to identify several factors influencing medication adherence, micro-level factors were the most frequently discussed.Conclusion: Findings from this study indicate that strategies to optimize medication adherence for persons with SCI/D should be multi-faceted.

Clinical performance of chairside monolithic lithium disilicate glass-ceramic CAD-CAM crowns.

To evaluate the clinical performance and the effect of various patient and provider-related factors on the longevity of chairside monolithic posterior lithium disilicate glass-ceramic (LDGC) computer-aided design (CAD)-computer-aided manufacturing (CAM) crowns provided by predoctoral students. A sample of posterior LDGC CAD-CAM crowns was evaluated. Crown preparations were milled chairside using the CEREC Omnicam system and cemented with Rely-X Unicem or Calibra Universal resin cements. Clinical assessment of the crowns and supporting periodontal structures was performed using the modified California Dental Association (CDA) criteria. Intraoral photographs as well as radiographs were taken for further assessment by two evaluators. Kaplan-Meier survival analysis was performed. A total of 40 crowns were inserted in 32 patients and evaluated for 4 years. Three complications were observed (two-technical and one-biological). No chipping or fracture of crowns was observed. No significant association was found between age, sex, periodontal condition, tooth type, tooth vitality, cement type, and longevity. The 4-year cumulative survival and success rates were 95.0 and 92.3%, respectively. Chairside LDGC CAD-CAM crowns exhibited a high survival rate after 4 years in function and were shown to be a viable and reliable treatment option for posterior teeth. The high survival rate of chairside CAD-CAM crowns observed in this study suggests the likelihood of predictable performance in the predoctoral setup.

EFL learners’ corrective feedback decision-making in task-based peer interaction

This laboratory-based research investigated how 40 university EFL learners responded to their peers’ linguistic errors and made their moment-to-moment decisions of whether or not to provide corrective feedback (CF) to their peers’ errors in task-based peer interaction. Data from the transcripts of videotaped pair interaction and audio-taped stimulated recall interviews were utilized and analysed to report the findings. Results showed that learners did not provide CF to their partners frequently and of the three CF strategies, they favoured recast over prompts and explicit correction. Furthermore, more morphosyntactic errors than lexical and phonological errors were provided CF. More importantly, results revealed that learners’ CF decision-making was mediated by six categories of factors: provider-related factors (e.g. providers’ lack of knowledge), receiver-related factors (e.g. receivers’ showing signs of seeking help), task-related factors (e.g. the time of story happening), error-related factors (e.g. salience of errors), and interpersonal factors (e.g. peer relationship). Implications are discussed especially regarding the important role of teachers in raising learners’ language awareness in peer interaction.

How European primary care practitioners think the timeliness of cancer diagnosis can be improved: a thematic analysis

BackgroundNational European cancer survival rates vary widely. Prolonged diagnostic intervals are thought to be a key factor in explaining these variations. Primary care practitioners (PCPs) frequently play a crucial role...

Factors Associated With Opioid Prescribing for Distal Upper Extremity Fractures at a Pediatric Emergency Department.

The aims of this study were to describe the prescribing patterns of oxycodone for patients with distal upper extremity fractures and to evaluate factors that influence the quantity of oxycodone prescribed at discharge. We retrospectively studied oxycodone prescriptions for patients with upper extremity fractures presenting to a single center tertiary pediatric emergency department (ED) from June 1, 2014, to May 31, 2016. We used logistic regression models to evaluate the association of opioid administration in the ED, fracture reduction under ketamine sedation, initial pain scores (low, medium, and high), patient demographics, and type of prescriber (residents, attendings, fellows, and advanced registered nurse practitioners) with oxycodone prescription at discharge and the number of doses prescribed (≤12 or >12 doses). A total of 1185 patients met the inclusion criteria. Of these, 669 (56%) were prescribed oxycodone at discharge. Children with fractures requiring reduction had 13 times higher odds [95% confidence interval (CI), 9.45-20.12] of receiving an oxycodone prescription compared with children with fractures not requiring reduction. Opioid administration in the ED was associated with 7.5 times higher odds (95% CI, 5.41-10.51) of receiving an outpatient prescription. Children were more likely to have a higher quantity of oxycodone prescribed if they had a fracture reduction in the ED [odds ratio (OR), 1.73; 95% CI, 1.20-2.50], received an opioid in the ED (OR, 2.13; 95% CI, 1.43-3.20), or received their prescription from an emergency medicine resident (OR, 2.8; 95% CI, 1.44-5.74). Opioid prescribing differs based on patient- and provider-related factors. Given the variability in prescribing patterns, changing suggested opioid prescriptions in the electronic medical record may lead to more consistent practice and therefore decrease unnecessary prescribing while still ensuring adequate outpatient analgesia.

Determinants of inappropriate setting allocation in the care of patients with type 2 diabetes: A population-based study in Reggio Emilia province.

The study aims to describe the distribution of patients with type 2 diabetes (T2D) by care plan and to highlight determinants of underuse and overuse of integrated care (IC). This cross-sectional study included all T2D patients resident in Reggio Emilia on 31/12/2015 based on the population-based diabetes registry. Eligibility for IC requires good glycaemic control, no rapid insulin, no kidney failure and no diabetes complications. We calculated the proportion of IC underuse and overuse and adjusted prevalence estimate using multivariate logistic regression. Determinants were age, sex, citizenship, district of residence and time since diagnosis. Of 29,776 patients, 15,364 (51.6%) were in diabetes clinic plan, 9851 (33.1%) in IC plan and 4561 (15.3%) not in any care plan (i.e., in Other group). There were 10,906 (36.6%) patients eligible for IC, of whom 1000 in Other group. When we adjusted for all covariates and restricted the analysis to patients included in care plans, the proportion of those eligible for IC plan but cared for in diabetes clinic plan (i.e. underuse of IC) was 28% (n = 3028/9906; 95%CI 27–29). Similarly, the proportion of those not eligible for IC but cared for in IC plan (i.e. overuse of IC) was 11% (n = 1720/11,896; 95%CI 10–11).The main determinant of both IC underuse and overuse was the district of residence. Foreign status was associated with underuse (37%; 95%CI 33–43), while old age (≥80 years) with both underuse (36%; 95%CI 0.33–0.38) and overuse (23%; 95%CI 22–25). The criterion for suspension of IC plan most frequently found was renal failure, followed by hospitalization for diabetes-related complications. Patients are more often allocated to more specialized settings than not. Healthcare provider-related factors are the main determinants of inappropriate setting allocation.

Examining intrafamilial communication of colorectal cancer risk status to family members and kin responses to colonoscopy: a qualitative study

BackgroundFirst-degree relatives (FDRs) of probands with colorectal cancer (CRC) may be at increased risk of CRC and require colonoscopy. Proband disclosure about this risk and need for colonoscopy is essential for FDRs to take appropriate action. Low colonoscopy rates are reported among FDRs and little is known about the proband disclosure process. A better understanding of the barriers surrounding colonoscopy and disclosure is needed.MethodsCRC probands (n = 16) and FDRs (n = 9), recruited from a Canadian CRC Consortium, completed interviews to determine barriers to disclosure and colonoscopy, respectively. Interviews were analyzed using thematic analysis and participants’ motivation to disclose to FDRs or undertake colonoscopy was categorized into Stages of Change (i.e., Precontemplation, Contemplation, Preparation, Action, or Maintenance) using the transtheoretical model.Results25% of probands had not disclosed to any first-degree kin and were categorized in the Precontemplation or Contemplation Stage of Change. Barriers to disclosure included lack of information, negative expectations about familial reaction, assuming FDRs were aware of risk or already being screened, dysfunctional family dynamics, and cultural barriers. 75% of FDRs were categorized in the Precontemplation or Contemplation Stage of Change. Barriers included negative perceptions about colonoscopy, health-care provider related factors, practical concerns, and lack of information about CRC, risk, and colonoscopy.ConclusionsIn the absence of barriers such as cost and accessibility, this Canadian sample still reported several challenges to disclosure and colonoscopy adherence. Future research should explore interventions such as motivational interviewing to improve proband disclosure and to increase FDR adherence to colonoscopy.

Provider barriers to the uptake of isoniazid preventive therapy among people living with HIV in Ethiopia.

Sixty-seven government health facilities providing tuberculosis (TB) and human immunodeficiency virus (HIV) services across Ethiopia. To examine clinician barriers to implementing isoniazid preventive therapy (IPT) among people living with HIV. A cross-sectional study to evaluate the provider-related factors associated with high IPT coverage at the facility level. On bivariate analysis, the odds of high IPT implementation were lower when clinicians felt patients were negatively affected by the side effects of IPT (OR 0.18, 95%CI 0.04-0.81) and perceived that IPT increased multidrug-resistant TB (MDR-TB) rates (OR 0.66, 95%CI 0.44-0.98). The presence of IPT guidelines on site (OR 2.93, 95%CI 1.10-7.77) and TB-HIV training (OR 3.08, 95%CI 1.11-8.53) had a positive relationship with high IPT uptake. In the multivariate model, clinician's perception that active TB was difficult to rule out had a negative association with a high IPT rate (OR 0.93; 95%CI 0.90-0.95). Clinician impression that ruling out active TB among HIV patients is difficult was found to be a significant barrier to IPT uptake. Continued advancement of IPT relies greatly on improving the ability of providers to determine IPT eligibility and more confidently care for patients on IPT. Improved clinician support and training as well as development of new TB diagnostic technologies could impact IPT utilization among providers.

Healthcare provider perspectives on the uptake of the human papillomavirus vaccine among newcomers to Canada: a qualitative study

ABSTRACT Human papillomavirus is among the most common sexually transmitted infections in the world. Newcomers, defined in Canada as foreign-born individuals who are either immigrants or refugees, but may also include students and undocumented migrants, face numerous barriers to HPV vaccination. This study sought to understand, from the perspective of healthcare providers, barriers and facilitators to HPV vaccination, and recommendations to improve HPV vaccine uptake among newcomers. Semi-structured interviews were conducted with 10 healthcare providers between March and April 2018. Data were analyzed at the manifest level using a Qualitative Content Analysis approach. Categories of barriers to vaccination included: access, communication, knowledge, culture, and provider-related factors. Facilitators included targeted health promotion; understanding the relevance of HPV vaccination; trusting the healthcare system; and cultural sensitivity. Two overarching recommendations were to publicly fund the HPV vaccine, and enhance language- and culturally-appropriate health promotion activities. Further research should explore informational desires and needs from the perspective of newcomers to inform strategies to promote equitable HPV vaccine coverage.

Cultural Competency Matters: Calling for a Deeper Understanding of Healthcare Disparities Among Nurse Leaders.

Healthcare disparities for racial and ethnic minority patients are a serious issue in the United States. Although socioeconomic factors are a key contributor to these disparities, there are many other influences, related to the patient, system, and provider. A key strategy to address provider-related factors is to assess the cultural competence of caregivers. Utilizing a survey and interviews of AONE members, this study explored the influences affecting the ability of nurse leaders to lead their teams in providing culturally competent care. The study found that nurse leaders need a deeper understanding of the presence of healthcare disparities for racial and ethnic minority patients, more formalized training, and increased opportunities to reflect on their own abilities and potential for bias. Cultural competence must be a strategic priority, providing resources for training, and by holding leaders accountable to improve the level of cultural competence of their teams.

Recommendations for Driving After Neuropsychological Assessment: A Survey of Neuropsychologists

Objective: To determine which patient, provider and practice-related characteristics are associated with increased likelihood of driving-related recommendations following a neuropsychological evaluation.Method: A total of 309 clinical neuropsychologists completed a survey evaluating the frequency with which they made various driving-related recommendations (e.g., take an on-road driving test) to a variety of clinical populations. Information regarding patient characteristics (e.g., perceived likelihood of adhering to recommendations), provider-related characteristics (e.g., years in practice) and practice-related characteristics (e.g., region of North America) were also collected. Correlation coefficients and multiple linear regressions controlling for patient diagnoses were used to examine which characteristics predicted greater likelihood of driving recommendations broadly. Significant characteristics were then entered into regressions to examine independent contributions of each characteristic to the likelihood of each individual driving recommendation.Results: Neuropsychologists reported giving a range of driving recommendations to most clinical populations, with the exception of patients with psychiatric diagnoses. Several characteristics (e.g., patient impairment) were associated with greater likelihood of driving recommendations broadly. After controlling for diagnoses, three significant predictors emerged: higher frequency of individualized recommendations, greater caregiver presence, and greater number of recommendations given. All three characteristics generally predicted frequency of all individual driving recommendations.Conclusions: While patients’ diagnoses may be indicative of whether they receive driving-related recommendations, certain patient and provider-related factors also uniquely contribute to the likelihood of driving-related recommendations after neuropsychological assessment.

Health Care-Related Correlates of Cervical Cancer Screening among Sexual Minority Women: An Integrative Review.

Sexual minority women (SMW; lesbian, bisexual, nonheterosexual women) may have lower rates of cervical cancer screening than heterosexual women. Health care-related factors may explain some of the variation in cervical cancer screening rates among SMW. We aimed to synthesize published evidence of health care-related correlates of cervical cancer screening among SMW. We searched PubMed, CINAHL, and PsycINFO databases for English-language studies published between January 2000 and March 2017 that 1) assessed sexual identity or the sexual partners of female participants, 2) included cervical cancer screening as a main outcome of interest, and 3) measured at least one health care-related variable in addition to cervical cancer screening. We excluded articles that 1) reported on non-US samples or 2) did not report original research. We reviewed the sample, methods, and findings of 17 studies. We then summarized current knowledge about health care-related factors across 3 categories and generated recommendations for clinical practice and future research. Several health care-related factors such as previous contraception use, having a primary care provider, knowledge of screening recommendations, and disclosing sexual orientation to providers were consistently positively associated with cervical cancer screening. Three groups of factors-previous health care use, health care provider-related factors, and belief-related factors-account for a substantial part of the variation in cervical cancer screening among SMW. Several gaps in knowledge remain that could be addressed by recruiting more diverse samples of SMW with improved generalizability. Clinicians and clinical institutions can address factors associated with low rates of screening among SMW by preventing sexual orientation-based discrimination, inviting sexual orientation disclosure, and offering cervical cancer screening to SMW at a variety of health care encounters. Future research should examine how the location of care and health care provider type affect SMW's cervical cancer screening behaviors and should test the effectiveness of health care interventions designed to address sexual orientation-related disparities.

Use of new interactive patient-provider software improves patient satisfaction and outcomes-a retrospective single-center study.

BackgroundWhile a number of studies have explored patient- and provider-related factors contributing to quality of care, few studies have explored the role of technology in improving quality and optimizing patient-provider communication. This study explores the use of an interactive patient-provider software platform (IPSP) at a single institution. Specifically, we compared: (1) patient satisfaction scores, (2) complication rates, and (3) readmission rates before and after the use of an IPSP on patients undergoing total hip arthroplasty and total knee arthroplasty.Material and MethodsA retrospective review was performed on all total hip arthroplasty and total knee arthroplasty patients who completed a Press Ganey survey at a single institution between the years 2014 and 2017. Primary outcomes included Press Ganey patient satisfaction scores and 90-day complication and readmission rates. Mann-Whitney U testing and chi-squared analyses were conducted to assess continuous and categorical variables, respectively.ResultsAnalysis revealed an improvement in median Clinician and Group Consumer Assessment of Healthcare Providers and Systems (89 vs 97) and Hospital for Consumer Assessment of Healthcare Providers and Systems scores (9 vs 10; P < .001) between pre-IPSP and post-IPSP. There was a decrease in 90-day complication rates (17.3 vs 11.2%; P = .035) but no decrease in readmission rates (0.30 vs 0.18%, P = .322) between the 2 time points.ConclusionsThe use of an IPSP proved instrumental in improving patient satisfaction and lowering 90-day complication rates at a single institution. The implementation of an IPSP may prove beneficial to arthroplasty surgeons and health-care institutions alike seeking to optimize the quality of care. Larger multicenter studies are necessary to validate the results of the present study.

The Compelling and Persistent Problem of Bipolar Disorder Disguised as Major Depression Disorder: An Integrative Review [Formula: see text

Up to 40% of patients with bipolar disorder are misdiagnosed, usually with major depression disorder. The purpose was to describe the current state of the science of the misdiagnosis of bipolar disorder, with the ultimate goal of improving psychiatric diagnostic workups including screening. An integrative review was conducted using standard criteria for evaluating research articles. Forty-nine articles met the eligibility criteria. Articles explored patient-related and health care provider-related factors contributing to the misdiagnosis of bipolar disorder as well as consequences of misdiagnosis. Clinically oriented, reliable, and valid screening tools for bipolar disorder also were reviewed. Awareness of multiple, challenging patient-related factors and more comprehensive assessment and screening by health care providers may reduce misdiagnosis.

Potential predictive factors for successful referral from specialist mental-health services to less intensive treatment: A concept mapping study

Referring patients from specialist mental-health services (provided by multiple healthcare service providers and aimed at relieving symptoms of mental illness) to less intensive care (provided by a nurse or psychologist in cooperation with a general practitioner and aimed at improving quality of life) is feasible from the perspective of patients, service providers, and mental-health services. However, it is unclear which patients are most suitable for referral to less intensive care. In this study, we used concept mapping to identify factors that might determine whether a referral from specialist mental services to less intensive care might be successful. Participants (N = 34) were recruited from different parts of the Netherlands and included general practitioners, peer workers, community mental-health nurses, and social workers from several services who were based in different neighborhoods. The participants generated 54 statements (31 after clean-up), which were sorted into five clusters and rated on their expected ability to predict successful referral. Ordered from highest to lowest on expected predictive value, the clusters of factors were: Patient characteristics, patients’ informal support system, patients’ social situation, organization of services, and service provider related factors. The ordering was the same for all of the service providers, except that general practitioners expected the organization of services to be the most predictive. The ordering of the clusters is mostly consistent with existing knowledge about recovery during mental healthcare. In order to further improve the number of successful referrals from specialist mental-health services to less intensive care, a prospective prediction study is needed.

Maternal near-miss audit in the Metro West maternity service, Cape Town, South Africa: A retrospective observational study

Background. A maternal near-miss is defined as a life-threatening pregnancy-related complication where the woman survives. The World Health Organization (WHO) has produced a tool for identifying near-misses according to criteria that include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. Maternal deaths have been audited in the public sector Metro West maternity service in Cape Town, South Africa, for many years, but there has been no monitoring of near-misses. Objectives. To measure the near-miss ratio (NMR), maternal mortality ratio (MMR) and mortality index (MI), and to investigate the near-miss cases. Methods. A retrospective observational study conducted during 6 months in 2014 identified and analysed all near-miss cases and maternal deaths in Metro West, using the WHO criteria. Results. From a total of 19 222 live births, 112 near-misses and 13 maternal deaths were identified. The MMR was 67.6 per 100 000 live births and the NMR 5.83 per 1 000 live births. The maternal near-miss/maternal death ratio was 8.6:1 and the MI 10.4%. The major causes of near-miss were hypertension ( n =50, 44.6%), haemorrhage ( n =38, 33.9%) and puerperal sepsis ( n =13, 11.6%). The first two conditions both had very low MIs (1.9% and 0%, respectively), whereas the figure for puerperal sepsis was 18.9%. Less common near-miss causes were medical/surgical conditions ( n =7, 6.3%), non-pregnancy-related infections ( n =2, 1.8%) and acute collapse ( n =2, 1.8%), with higher MIs (33.3%, 66.7% and 33.3%, respectively). Critical interventions included massive blood transfusion (34.8%), ventilation (40.2%) and hysterectomy (30.4%). Considering health system factors, 63 near-misses (56.3%) initially occurred at a primary care facility, and the patients were all referred to the tertiary hospital; 38 (33.9%) occurred at a secondary hospital, and 11 (9.8%) at the tertiary hospital. Analysis of avoidable factors identified lack of antenatal clinic attendance (11.6%), inter-facility transport problems (6.3%) and health provider-related factors (25.9% at the primary level of care, 38.2% at secondary level and 7.1% at tertiary level). Conclusions. The NMR and MMR for Metro West were lower than in other developing countries, but higher than in high-income countries. The MI was low for direct obstetric conditions (hypertension, haemorrhage and puerperal sepsis), reflecting good quality of care and referral mechanisms for these conditions. The MIs for non-pregnancy-related infections, medical/surgical conditions and acute collapse were higher, suggesting that medical problems need more focused attention.

Maternal near-miss audit in the Metro West maternity service, Cape Town, South Africa: A retrospective observational study.

A maternal near-miss is defined as a life-threatening pregnancy-related complication where the woman survives. The World Health Organization (WHO) has produced a tool for identifying near-misses according to criteria that include the occurrence of a severe maternal complication together with organ dysfunction and/or specified critical interventions. Maternal deaths have been audited in the public sector Metro West maternity service in Cape Town, South Africa, for many years, but there has been no monitoring of near-misses. To measure the near-miss ratio (NMR), maternal mortality ratio (MMR) and mortality index (MI), and to investigate the near-miss cases. A retrospective observational study conducted during 6 months in 2014 identified and analysed all near-miss cases and maternal deaths in Metro West, using the WHO criteria. From a total of 19 222 live births, 112 near-misses and 13 maternal deaths were identified. The MMR was 67.6 per 100 000 live births and the NMR 5.83 per 1 000 live births. The maternal near-miss/maternal death ratio was 8.6:1 and the MI 10.4%. The major causes of near-miss were hypertension (n=50, 44.6%), haemorrhage (n=38, 33.9%) and puerperal sepsis (n=13, 11.6%). The first two conditions both had very low MIs (1.9% and 0%, respectively), whereas the figure for puerperal sepsis was 18.9%. Less common near-miss causes were medical/surgical conditions (n=7, 6.3%), non-pregnancy-related infections (n=2, 1.8%) and acute collapse (n=2, 1.8%), with higher MIs (33.3%, 66.7% and 33.3%, respectively). Critical interventions included massive blood transfusion (34.8%), ventilation (40.2%) and hysterectomy (30.4%). Considering health system factors, 63 near-misses (56.3%) initially occurred at a primary care facility, and the patients were all referred to the tertiary hospital; 38 (33.9%) occurred at a secondary hospital, and 11 (9.8%) at the tertiary hospital. Analysis of avoidable factors identified lack of antenatal clinic attendance (11.6%), inter-facility transport problems (6.3%) and health provider-related factors (25.9% at the primary level of care, 38.2% at secondary level and 7.1% at tertiary level). The NMR and MMR for Metro West were lower than in other developing countries, but higher than in high-income countries. The MI was low for direct obstetric conditions (hypertension, haemorrhage and puerperal sepsis), reflecting good quality of care and referral mechanisms for these conditions. The MIs for non-pregnancy-related infections, medical/surgical conditions and acute collapse were higher, suggesting that medical problems need more focused attention.

Oral anticoagulant re-initiation following intracerebral hemorrhage in non-valvular atrial fibrillation: Global survey of the practices of neurologists, neurosurgeons and thrombosis experts.

BackgroundWhile oral anticoagulants (OACs) are highly effective for ischemic stroke prevention in atrial fibrillation, intracerebral hemorrhage (ICH) remains the most feared complication of OAC. Clinical controversy remains regarding OAC resumption and its timing for ICH survivors with atrial fibrillation because the balance between risks and benefits has not been investigated in randomized trials.Aims/HypothesisTo survey the practice of stroke neurologists, thrombosis experts and neurosurgeons on OAC re-initiation following OAC-associated ICH.MethodsAn online survey was distributed to members of the International Society for Thrombosis and Haemostasis, Canadian Stroke Consortium, NAVIGATE-ESUS trial investigators (Clinicatrials.gov identifier NCT02313909) and American Association of Neurological Surgeons. Demographic factors and 11 clinical scenarios were included.ResultsTwo hundred twenty-eight participants from 38 countries completed the survey. Majority of participants were affiliated with academic centers, and >20% managed more than 15 OAC-associated ICH patients/year. Proportion of respondents suggesting OAC anticoagulant resumption varied from 30% (for cerebral amyloid angiopathy) to 98% (for traumatic ICH). Within this group, there was wide distribution in response for timing of resumption: 21.4% preferred to re-start OACs after 1–3 weeks of incident ICH, while 25.3% opted to start after 1–3 months. Neurosurgery respondents preferred earlier OAC resumption compared to stroke neurologists or thrombosis experts in 5 scenarios (p<0.05 by Kendall’s tau).ConclusionsWide variations in current practice exist among management of OAC-associated ICH, with decisions influenced by patient- and provider-related factors. As these variations likely reflect the lack of high quality evidence, randomized trials are direly needed in this population.

Risk factors for infection following primary total knee replacement

Purpose: Information about risk factors can be used to target preventive measure on susceptible patient subgroups. The purpose of study was to determine the risk factors for infection following primary knee replacement. Methods: Between April 2014 and January 2016, total 1599 primary total knee replacements were carried out in 1374 patients, among them 1161 (933 female and 228 male) cases were available for final study. Patients were divided into without infection and had deep infection. Patients-related risk factors and provider-related risk factors were determined. Results: Out of 1161 patients, 16 patients had deep infection with infection rate was 1.38 %. There was no significant statistically between age, diagnosis, obesity and malnutrition with infection. Total 16.6 % were smoker, among infected group 37.5% patients were smoker with odds ratio 3.01 and P value 0.013 (<0.05). In study 12.4% patients had diabetics mellitus, in infected group 25% had with odds ratio 2.35 and p value 0.016 (<0.05). Total 2.6% patients had history of steroid use, among infected group 12.5% patients with odds ratio 5.39 and p value less than 0.05. Regarding the provider-related risk factors, mean duration of surgery was 130.9 min and mean duration of hospital stay was 10.95 days with both had no significant statistically. Mean blood loss during surgery was 751.47 ml and mean amount of blood transfusion was 596.08 ml with both had association with infection (p<0.05). Conclusions: Smoking, diabetes mellitus, steroid use, total blood loss and blood transfusion were significance risk factors for infection after total knee replacement.