Doctor Shopping Behaviour and Its Predisposing Factors amongst Dermatology Patients / Jurnal Sains Kesihatan Malaysia

@#Doctor shopping increases health economic burden and morbidities. Its prevalence and predisposing factors have to beidentified in order to formulate preventive measures. We aimed to determine the prevalence of doctor shopping, its reasonsand predisposing factors by conducting a cross sectional study of new patients at the Dermatology Clinic, UniversitiKebangsaan Malaysia Medical Centre (UKMMC). Doctor shopping was defined as having consultation with ≥3 healthcareproviders without a referral for the same illness prior to the patients’ visit to UKMMC. Reasons and contributing factorswere classified as disease, healthcare provider, logistic and cost related. Data was collected by a face to face interview.Dermatology Life Quality Index (DLQI) questionnaire determined disease impact on the patients. A total of 58 (55.8%)female and 46 (44.2%) male patients participated. Referral was patient-initiated in 51.9% while 40.4% were doctorshopping. Age, gender, ethnicity, income, occupation and type of health finance provider were not associated with thisbehaviour. About 95% doctor shopped due to disease factors: searching for a cure (95.2%), lack of improvement (88.1%),worsening disease (50.0%), dissatisfaction with treatment (31.0%), seeking other opinions (26.2%) and exploringtreatment options (26.2%). Impaired DLQI (OR 1.17; 95% CI 1.08,1.38), p 0.04, and disease related factors (OR 6.57; 95%CI 1.52, 7.72), p 0.041 were significant independent risk factors. Doctor shopping is very common among our patients.Reasons and predisposing factors are predominantly disease related. Patient education and counselling is important inmanagement of dermatological diseases to prevent doctor shopping.

Teleconsutoria e videoconferência como estratégia de educação permanente para as equipes de saúde da família / Teleconsultations and videoconferencing as a strategy of Permanent education for family health care teams / Teleconsutoría y videoconferencia como estrategias de educación permanente para los equipos de salud de la familia

A Educação a Distância, através do uso das Tecnologias de Informação e Comunicação superou os limites para capacitação das Equipes de Saúde da Família por meio da educação permanente. O estudo tem como objetivo avaliar a relação existente entre as áreas temáticas solicitadas nas teleconsultorias e os temas propostos para as videoconferências realizadas no período de janeiro de 2008 a dezembro de 2012. Trata-se de um estudo exploratório, com abordagem qualitativa. Foram utilizados dados secundários fornecidos pelo Núcleo de Telessaúde de uma faculdade de Minas Gerais. Foi realizada a análise dos registros de 495 teleconsultorias e 89 videoconferências. O estudo permitiu concluir a aproximação das áreas temáticas das dúvidas descritas nas teleconsultorias com os temas propostos para as videoconferências, indicando que os profissionais utilizam os recursos da Telessaúde para discutirem dúvidas da realidade assistencial. Constata-se a possibilidade de expansão do projeto, com ampliação de suas ações (AU).

Through the use of Information and Communication Technologies, distance education exceeded the limits for the qualification of family healthcare teams through permanent education. This study aims to evaluate the existing relation between the thematic areas that are requested in the teleconsultations and the themes proposed for videoconferences conducted between January 2008 and December 2012. It is an exploratory study with a qualitative approach. Secondary data provided by the Telehealth Nucleus of a university in Minas Gerais were used. Records of 495 teleconsultations and 89 videoconferences were analyzed. The study enabled the conclusion of the approximation of the thematic areas of the doubts described in the teleconsultations with the themes proposed for the videoconferences, indicating that the professionals use Telehealth resources to discuss questions about the health care reality. The possibility of expansion of the project and its actions was evidenced (AU).

La Educación a distancia, a través del uso de Tecnologías de Información y Comunicación, ha superado los límites para capacitación de los Equipos de Salud de la Familia por medio de la educación permanente. El estudio tiene como propósito evaluar la relación entre áreas temáticas solicitadas en las teleconsultorías y los temas propuestos para las videoconferencias realizadas en el periodo de enero de 2008 a diciembre de 2012. Es un estudio exploratorio, con abordaje cualitativo. Fueron utilizados datos secundarios fornecidos por el Núcleo de Telesalud de una facultad de Minas Gerais. Fue realizado el análisis de los registros de 495 teleconsultorías y 89 videoconferencias. El estudio posibilitó concluir la aproximación de áreas temáticas de las dudas descriptas en las teleconsultorías con los temas propuestos para las videoconferencias, apuntando que los profesionales utilizan los recursos de la Telesalud para discutir dudas de la realidad asistencial. Se constata la posibilidad de expansión del proyecto, con ampliación de sus acciones (AU).

Newer insights in teledermatology practice.

The study and practice of dermatology care using interactive audio, visual, and data communications from a distance is called teledermatology. A teledermatology practice (TP) provides teleconsultation as well tele-education. Initially, dermatologists used videoconference. Convenience, cost-effectiveness and easy application of the practice made "store and forward" to emerge as a basic teledermatology tool. The advent of newer technologies like third generation (3G) and fourth generation (4G) mobile teledermatology (MT) and dermatologists' interest to adopt tertiary TP to pool expert (second) opinion to address difficult-to-manage cases (DMCs) has resulted in a rapid change in TP. Online discussion groups (ODGs), author-based second opinion teledermatology (AST), or a combination of both are the types of tertiary TP. This article analyzes the feasibility studies and provides latest insight into TP with a revised classification to plan and allocate budget and apply appropriate technology. Using the acronym CAP-HAT, which represents five important factors like case, approach, purpose, health care professionals, and technology, one can frame a TP. Store-and-forward teledermatology (SAFT) is used to address routine cases (spotters). Chronic cases need frequent follow-up care. Leg ulcer and localized vitiligo need MT while psoriasis and leprosy require SAFT. Pigmented skin lesions require MT for triage and combination of teledermoscopy, telepathology, and teledermatology for diagnosis. A self-practising dermatologist and national health care system dermatologist use SAFT for routine cases and a combination of ASTwith an ODG to address a DMC. A TP alone or in combination with face-to-face consultation delivers quality care.

Second opinion and discrepancy in the diagnosis of soft tissue lesions at surgical pathology.

Objective: To determine the frequency and magnitude of discrepancies in the surgical pathological diagnosis of soft tissue lesions on review and second opinion in a histopathology center. Study Design: Cross-sectional, observational. Place and Duration of Study: Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, from April 2006 to May 2007. Materials and Methods: All the cases of soft tissue as well as bone lesions, irrespective of age and gender, which were referred for second opinion or review after being reported elsewhere, were included in the study. A panel of antibodies of soft tissue, epithelial and lymphoid markers was applied according to the requirements of each case. The cases were categorized as category A where there was concurrence between initial diagnosis and diagnosis at review. Category B included cases where there was disagreement in the specific diagnostic entity as per WHO classifications without therapeutic implications. Category C was cases where the category of benign or malignant diagnosis remained the same but there was disagreement in the specific diagnosis with definite therapeutic implications. Category D had diagnosis of benign changed to malignant while category E had cases where diagnosis of malignancy was changed to a benign lesion. Results: During the study period, 34 cases of soft tissue lesions were received for review and second opinion. The mean age of the patients was 39 ΁ 22 years and immunohistochemistry was performed in 21 (62%) of 34 cases. Concurrence between the review and initial diagnosis was seen in 18 (53%) cases (category A). Discrepancy in the diagnosis at review and initial consultation was seen in 16 (47%) cases. There were four (11.8%) cases that were placed in category B as the diagnosis of benign and malignant remained the same but the specific diagnostic entity was changed. Category C included eight (23.5%) cases where the review diagnosis changed the therapeutic modality despite the benign or malignant category remaining unchanged. All the cases in this category required immunohistochemistry as diagnosis of metastatic carcinoma was changed to sarcoma in two cases and diagnosis of sarcoma was changed to carcinoma in three cases. There was only one (2.9%) case in category D where a benign diagnosis was changed to malignant on review and three (8.8%) cases reported as malignant had a revised diagnosis of benign lesion, placing them in category E. Conclusion: In the absence of a quality assurance regulatory body to monitor and overlook the professional competence of practicing surgical pathologists, a mandatory review and second opinion should be undertaken whenever a major therapeutic endeavor is to be undertaken, regardless of the cost for the ultimate benefit of the patient.

Second Opinion Diagnoses of Cytologic Specimens on Consultation : Asan Medical Center Experience / 대한세포병리학회지

BACKGROUND: Second opinion diagnosis of outside pathology slides is a common practice for efficient and proper patient management. We analyzed cytology slides from outside hospitals submitted for a second opinion diagnosis to determine whether the second opinion diagnosis had any influence on patient care. METHODS: We reviewed 1,153 outside cytology slides referred to Asan Medical Center for second opinions from January, 2007, to December, 2007. All cases were categorized into three groups; no diagnostic discrepancy, minor diagnostic discrepancies (no impact on the management), and major diagnostic discrepancies (significant impact on the management and subsequent follow-up). RESULTS: The thyroid was the most common organ system (933 cases, 80.9%). Forty cases (3.6%) belonged to the major diagnostic discrepancy group and 149 cases (12.8%) to the minor discrepancy group. For validation of second opinion diagnoses in major discrepancy cases, subsequent biopsy or surgical resection specimens and clinical information were reviewed, which were available in 29 cases. The second opinion diagnoses resulted in alteration of clinical management in 21 of 29 cases. CONCLUSION: For all referred patients, second opinion diagnosis is important and mandatory for appropriate patient care.

Avaliação cardiológica pré-operatória: estudo de 255 casos / Preoperative cardiological consultation. A study of 255 patients

Objetivo - Estudo dos pedidos de avaliaçäo cardiológica pré-operatória em hospital de referência em cardiologia no contexto de hospital geral. Métodos - Foram estudados 255 pacientes no período de junho a dezembro de 1989, de idades entre 16 e 82 (média de 55) anos, 120 (47//) do sexo masculino e 135 (53//) do feminino, mediante questionário aplicado por ocasiäo da consulta médica. Resultados - As queixas principais foram a dor toráxica em 30 casos (11,8//), a dispnéia em 57 (22,4//), palpitaçöes em 13 (5,1//); 141 (55,3//) pacientes eram assintomáticos do ponto de vista cardiológicos. A hipertensäo arterial foi detectada no exame físico em 75 (29,4//) casos e o sopro cardíaco em 21(8,2//). Os diagnósticos mais freqüentes foram a hipertensäo arterial em 63(24,7//) casos, a insuficiência coronariana em 30 (11,8//), dos quais 13(5,1//) informavam ter sofrido infarto do miocárdio pregresso, a estenose aórtica em 5 (1,9//), outras valvopatias em 14(5,5//), disritimias cardíacas em 11(4,3//). Em 90 (35,4//) pacientes näo havia evidência de cardiopatia. Sessenta e cinco (25,5//) pacientes faziam uso de medicaçäo cardiológica e 171 (67//) doentes já se encontravam hospitalizados com vistas à operaçäo. O acompanhamento cardiológico posterior foi recomendado a 150 (58,8//) pacientes. Sete doentes faleceram por causas atribuídas a doença de base dos pacientes. Em nenhum caso a intervençäo cirúrgica foi contra-indicada em razäo da cardiopatia. Conclusäo - Na populaçäo estudada näo se pôde detectar efeito adverso das cardiopatias diagnosticadas na evoluçäo dos pacientes operados. A avaliaçäo cardiológica pré-opertória contribui näo só para os cuidados transoperatório e pós-operatório imediato, mas também permitiu orientar conveniência de seguimento médico a longo prazo

Purpose - To study preoperative cardiological consultations in a cardiology referral center in a general hospital Methods - Two hundred and fifty five patients were studied between June and December 1989; the ages ranged between 16 and 82 (mean 55) years, 120 (47%) wore male and 135 (53%) femule. A questionary was applied by the physicians during consultation. Results - Main symptoms were thoracic pain in 30 (11,8%) cases, dyspnea in 57 (22,4%), palpitations in 13 (5,1%). Symptoms of cardiac disease were absent in 141 (55,3%) patients. On physical examination arterial hypertension was detected in 75 (29,4%) cases and a cardiac murmur in 21 (8,2%). Diagnosis of coronary artery disease was made in 30 (11,8%) cases -13 (5,1%) with history of previous myocardial infarction, aortic valve stenosis in 5 (1,9%), other valvular heart diseases in 14 (5,5%), cardiac arrhythmias in 11 (4,3%). Heart disease was absent in 90 (35,4%) patients. Sixty-five (25,5%) patients were on drug therapy for heart diseases. Consultations were obtained for patients that had been already admitted to the hospital in 171 (67%) cases. Cardiological follow up was recommended to 150 (58,8%) patients. Seven patients died; the cause of the death was related to the primary disease. Contraindication for surgery imposed by cardiological evaluation did not occur. Conclusion - In this study, patients with heart disease tolerated the surgical procedures. Preoperative cardialogical evaluation added useful data for postoperative care and also for long term follow-up of the patients