Mejoras en la atención a personas con enfermedades crónicas en España. Declaración de posición común de la Sociedad Española de Medicina Interna y la Sociedad Española de Medicina Familiar y Comunitaria
https://www.elsevier.es/es-revista-atencion-primaria-27-articulo-mejoras-atencion-personas-con-enfermedades-S0212656719307620
PARTICIPA
lunes, 30 de diciembre de 2019
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La formacion en ecografia de los medicos de familia canadienses.
Canadian
national survey of family medicine residents on point-of-care ultrasound
training
METHODS
A bilingual (English and French) online survey of
Canadian family medicine residents was administered between March and June
2017. The survey was developed by a group of 8 POCUS experts, including
ultrasound academic leads with extensive teaching experience and publications
related to POCUS, as well as input from family medicine residents and a medical
student. Our group included physicians from McGill University in Montreal, Que;
the University of Ottawa in Ontario; the University of Manitoba in Winnipeg; Memorial
University of Newfoundland in St John’s; the University of Toronto in Ontario;
and Western University in London, Ont. This survey was designed to ask similar
questions to our survey of family medicine program directors to allow for
direct comparison.21 Both of
these surveys also had strong influence from previous surveys conducted by
Steinmetz et al and Hall et al, which were each independently validated, and so
we did not repeat external validation and pilot testing of this survey.18,25 The questions
were reviewed internally by our group of POCUS experts and altered multiple
times to maximize their clarity and avoid any biased language. The survey and
study design were approved by the provincial Health Research Ethics Board of
Memorial University. The final survey consisted of 3 sections: current training
status, perceived relevance of POCUS to primary care, and demographic
characteristics. There are 23 items in the survey, including multiple-choice
questions with single or multiple answers, rating-scale questions, and
Likert-type scales.
All family medicine residents of the 17 Canadian
family medicine residency programs were included in the study. Enhanced skills
residents were excluded from the study, as many of these programs, such as
emergency medicine, already have an integrated POCUS curriculum.
The target population was estimated to be 2645
first- and second-year family medicine residents nationwide based on Canadian
Resident Matching Service data and verified by respective site administrators.
Survey participants were entered into a random draw for gift cards of $50.
The first survey invitation was sent out via
e-mail on March 15, 2017, with reminder e-mails sent 1 and 2 months after the
original invitation. The survey was closed on June 30, 2017, at midnight to
avoid changes in our survey population associated with the new cohort of
residents who started on July 1. The invitation contained a short cover letter,
an abstract describing the objectives of the study, and a link to the online
consent form and survey. The survey link was sent to the study population
through individual e-mail using a private e-mailing list sent by respective
resident site coordinators and program administrators; individual e-mail using
a private e-mailing list sent by respective resident representatives of the
College of Family Physicians of Canada Section of Residents; a survey link
included in the e-newsletter of the residency program; a survey link posted on
Facebook groups of the residency program; and a private e-mailing list of the
Society of Rural Physicians of Canada. To ensure multiple surveys were not
completed by the same respondent, only 1 survey submission was accepted from a
single IP (Internet protocol) address.
The survey was distributed by SurveyMonkey. Raw
data were exported from SurveyMonkey into a Microsoft Excel spreadsheet. A
single data abstractor analyzed the survey responses and reported them as
percentages in tabular format. Responses were kept anonymous and all data were
reported in aggregate.
DISCUSSION
Our survey results demonstrate that most
residents express a strong interest in POCUS training and support the use of
POCUS in primary care practice. However, a formal POCUS curriculum has not yet
been incorporated into most Canadian family medicine residency programs. This
reiterates the results of our recent study of family medicine program
directors, who also expressed an interest in establishing a POCUS curriculum.
Despite this desire for training, currently only 3 family medicine residency programs
in Canada offer an established ultrasound curriculum.21
Implementing POCUS training in family medicine
residency programs has several potential barriers, including limited access to
ultrasound machines and qualified instructors.21 Aside from a
mandatory POCUS curriculum in residency programs, our results suggest a POCUS
elective or funding to take external POCUS training are potential solutions.
However, this can pose a substantial financial burden to residents, as these
electives and courses can cost between $1000 and $5000. Most residents (91.6%)
believed funding should come from residency programs to take these courses if
formal ultrasound training is unavailable. Increasingly, residency training
programs are facing budgetary constraints. Developing in-house training
programs or local POCUS electives would help mitigate these costs.
Most residents supported the inclusion of POCUS
in primary care practice and identified its main benefits as being a useful
adjunct to the physical examination and a rapid diagnostic tool, as well as
having the potential to reduce health care spending. Most residents would also
consider using POCUS regularly in their clinical practice if both the
appropriate training and access to an ultrasound machine were provided. These
views are similar to those in the previous study of family medicine program
directors, who also expressed favourable views of POCUS in primary care.21 Although
most evidence supporting POCUS use comes from emergency medicine, the movement
toward the inclusion of ultrasound in family medicine is supported by the
growing body of literature highlighting that POCUS use in primary care is
accurate, is safe, and has numerous applications for family practice.26–34
In conjunction with the results from our previous
survey, both residents and program directors believe ultrasound is useful in
clinical practice for AAA screening, obstetric indications, and procedural
guidance.21 The use of
ultrasound for these applications in primary care is well supported by
evidence. Research has demonstrated long-term mortality benefits associated
with ultrasound screening of asymptomatic patients for AAA. A recent Canadian
prospective study showed that office-based scans for AAA screening had a high
degree of correlation with hospital-based scans.13 The use of
ultrasound in primary care obstetrics is well documented, and the American
Academy of Family Physicians endorsed obstetric ultrasound as a core skill for
maternity care.35 A plethora
of literature supports the use of ultrasound by clinicians to guide a variety
of procedures commonly performed in primary care such as drainage of
subcutaneous abscesses, joint aspiration, intra-articular injection,
confirmation of intrauterine device placement, and paracentesis.15,36–39
Contrary to the results of the survey of program
directors, residents also considered the FAST examination and limited
echocardiography as useful applications. Although the FAST examination is well
established in the context of abdominal trauma to identify free fluid, it can
also be used in the primary care clinic to identify ascites.9 Residents
might consider it to be a useful POCUS application owing to their familiarity
with its use, as it is often the first application taught as an introduction to
bedside ultrasound. Evidence supporting the use of limited echocardiography in
primary practice is currently lacking. A study from Norway has demonstrated
that after undergoing an 8-hour training program, general practitioners were
able to assess left ventricular function using pocket-sized ultrasound with a
sensitivity and specificity of 78% and 83%, respectively.29 This skill
could be useful for family physicians to help determine the cause of patients
presenting with dyspnea including heart failure and pleural effusions.
Many primary care physicians work in a variety of
practice settings, including in community emergency departments, in palliative
care settings, and as hospitalists. This is also reflected in the residents’
responses (Table 1).
The use of POCUS is helpful in the many different practice settings in which
family physicians work.
Limitations
A limitation of this study was the overall
response rate of only 32.3% of Canadian family medicine residents. Previous
research on large population survey studies reported an average response rate
of 30% to e-mail surveys and our results are comparable.40,41 Similarly,
the 2007 National Physician Survey of Canadian physicians and residents
achieved an e-mail response rate of 29.9%.42 In a
meta-analysis of Web- and Internet-based surveys, Cook et al suggested that
response representativeness is more important than response rate.43 Representativeness
refers to how well the sample drawn for the questionnaire reflects the greater
population attributes. Overall, responses were fairly evenly distributed across
rural, urban or community, and academic teaching units, with 29.6%, 38.2%, and
32.2% response rates, respectively. Another limitation to our survey study is
the lack of flexibility in response format. In our study of this large
population, multiple-choice responses, binary responses, and Likert scales
better quantify the predominant opinions of the surveyed population, but in
doing so, we lose certain nuances in the opinions expressed. When possible, we
allowed for an “other (please specify)” option for individual responses.
However, a qualitative study on the views of family medicine residents and
physicians would help to further our understanding of the role of POCUS in
primary care.
Finally, it is important to note that most of our
resident respondents do not have any formal training in POCUS. Only 33.2%
agreed or strongly agreed that they were familiar with the literature on POCUS
use. This is higher than family medicine program directors and academic leads,
of whom only 21% either agreed or strongly agreed.21 Thus, most
family medicine residents and program directors are not entirely familiar with
the current literature available on POCUS use, and so opinions on POCUS being
used to alter clinical decision making or having no negative effect on patient
care might not be evidence based. A future goal will be educating both
residents and program directors on the emerging evidence for POCUS use in
family medicine.
Conclusion
This is the largest survey identifying the
perceived need of family medicine residents for POCUS training. There is
overwhelming support for and interest in POCUS by family medicine residents
across Canada. Despite this, only 18.4% of residents currently receive formal
POCUS training through their residency programs. Consistent with our recent
family medicine program directors’ survey on POCUS, most believe training
should be incorporated into their residency curricula. Most residents believe
that POCUS would positively affect primary care and would consider using
ultrasound regularly in their clinical practice if they had the proper
training.
domingo, 15 de diciembre de 2019
Paliativos pediatria, importancia de los horarios de trabajo enhospital sobre resultados en salud.
The clinical practice guideline palliative care for children and other strategies to enhance shared decision-making in pediatric palliative care; pediatricians’ critical reflections
sábado, 14 de diciembre de 2019
viernes, 13 de diciembre de 2019
Changes in the Place of Death in the United States
TO THE EDITOR:
Where people die is an important determinant of patient and caregiver experience. To assess changes in place of death, we analyzed data from the Centers for Disease Control and Prevention and the National Center for Health Statistics database for natural deaths in the United States from 2003 through 2017. Cause of death was defined as the medical condition that had started the events that led directly to death, as recorded by the physician on the death certificate.1 Deaths from external causes were excluded. Between 2003 and 2017, there were nearly 35.2 million natural deaths (Figure 1). Most were attributed to cardiovascular disease (29.3%), followed by cancer (24.5%), respiratory disease (10.5%), dementia (7.9%), and stroke (5.9%).
In 2003, a total of 905,874 deaths occurred in hospitals (39.7%), which decreased to 764,424 (29.8%) in 2017, whereas the number of deaths at nursing facilities decreased from 538,817 (23.6%) to 534,714 (20.8%). The number of deaths at home increased from 543,874 (23.8%) in 2003 to 788,757 (30.7%) in 2017, whereas the number of deaths at hospice facilities increased from 5395 (0.2%) to 212,652 (8.3%). These trends were seen across all disease groups.
Younger patients, female patients, and racial and ethnic minorities had lower odds of death at home than did older patients, male patients, and white patients. Patients with cancer had the greatest odds of death at home and death at a hospice facility and the lowest odds of death at a nursing facility relative to other conditions. Patients with dementia had the greatest odds of death at a nursing facility, and patients with respiratory disease had the greatest odds of death at a hospital. Patients with stroke had the lowest odds of death at home, and patients with cardiovascular disease had the lowest odds of death at a hospice facility relative to other conditions.
Home has surpassed the hospital as the most common place of death in the United States for the first time since the early 20th century.2 Hospital deaths remained common in 2017, although the percentage in the United States was lower than in Canada (59.9%)3 and England (46.0%).4 Death at home is preferred by most people, but for many this might not be possible or preferable.5 Although we could not determine from the data whether hospice services were provided at home or at nursing facilities or whether some assisted-living facilities were categorized as home, data derived from death certificates provide the broadest assessment of place of death despite their limitations. The trends noted here represent progress; however, more information about the experience of patients dying at home is needed to develop policies and services that ensure high-quality end-of-life care. These findings should lead to prioritizing improvements in access to high-quality home care for older Americans with serious illnesses.
Sarah H. Cross, M.S.W., M.P.H.
Duke University Sanford School of Public Policy, Durham, NC
Duke University Sanford School of Public Policy, Durham, NC
Haider J. Warraich, M.D.
Veterans Affairs Boston Healthcare System, Boston, MA
hwarraich@partners.org
Veterans Affairs Boston Healthcare System, Boston, MA
hwarraich@partners.org
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
Supplementary Material
jueves, 12 de diciembre de 2019
domingo, 8 de diciembre de 2019
miércoles, 4 de diciembre de 2019
Centre de Salut "El Raval" - Elx: Bon día, os dejo aquí el enlace sobre el algoritmo...
Centre de Salut "El Raval" - Elx: Bon día, os dejo aquí el enlace sobre el algoritmo...: Bon día, os dejo aquí el enlace sobre el algoritmo de Semfyc y redgdps publicado este año para completar la información acerca de la diabete...
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