Can artificial intelligence increase the efficiency of referrals from primary to specialized care?

The overload of the current healthcare model makes the search for strategies to improve process efficiency essential. An artificial intelligence (AI) program based on Natural Language Processing pipelines (1-5) was used. It analyzed the referrals from primary care to Gastroenterology in the health area corresponding to our hospital in order to identify the most frequent reasons for consultation and to assign them a protocol for the performance of complementary tests before being seen for the first time in specialized care. We compared all referrals received in the first half of 2018, prior to the implementation of the AI pathway July 2018, with those received in the first half of 2019. Our aim was to evaluate the efficiency of this program in terms of discharges, need for additional tests and the number of follow-up visits required (number of follow-up visits/number of first visits in a given time period, FU/F index). In 2018, 1799 referrals were received, 1309 within our health area and 490 from outside the area. In 2019, 2261 referrals were received, 1392 from our area and 869 out-of-area. The AI pathway was applied to 31.4% of the area-referred patients. Overall, in 2019, the number of blood tests and CT scans requested at the first visit decreased (55.3 vs 61.4% and 4.4 vs 7.4% respectively, p<0.05 for both comparisons). The FU/F index in 2019 was 1.9 ± 0.04 vs 2.26 ± 0.07 in 2018 (p<0.05). When analysing patients from our health area, a higher number of discharges at the first consultation was observed during 2019 The number of requested supplementary exams among patients referred using the AI pathway was reduced compared to 2018. The FU/F index in patients referred using the AI pathway was 1.72 ± 0.08 vs 2.25 ± 0.08 in 2018 (p<0.05) and 1.93 ± 0.07 in those referred through the standard pathway in 2019 (p=0.07). Among patients referred from outside our health area, the number of endoscopies requested in 2019 was higher. The FU/F index improved in 2019 (1.95 ± 0.06 vs 2.29 ± 0.13, p<0.05). The number of patients referred using the AI pathway remains low, which could explain the lack of differences observed in the number of discharges or tests requested compared to patients referred via the standard pathway. However, the number of endoscopies and follow up visits requested for these patients did decrease.

Preferencias por las decisiones compartidas en pacientes con depresión / Depressive patients' preferences in shared decision-making / Preferências pelas decisões compartilhadas em pacientes com depressão

This study analyzed the role of psychological processes predicting depressed patients' preferences in clinical decision-making about psychiatric treatment. 462 patients diagnosed with depressive disorders, acute or recurrent, participated in a crosssectional survey. Most participants preferred collaborative-passive or totally passive roles. Results showed no significant differences between acute and recurrent patients in their preference of participation in decision-making, but longer treatment duration was associated with a more passive style. MANCOVA, controlling age, educational level and treatment duration variables, showed that collaborative and passive patients had a greater locus of control focused on their psychiatrist than active patients. Gender differences were found. Men showed greater internal locus of control and psychological reactance, while women showed greater external locus of control focused on chance. Regression analysis indicated that, for men, passive preferred role was explained by external locus centered on their psychiatrist. However, age registered the highest weight for women' passive decision-making, followed by the locus focused on chance, locus focused on the psychiatrist and lower self-efficacy. Our findings suggest the need to study shared decision-making from a differential perspective that involves psychological processes and the impact of these processes in adherence to medical treatments.

En el presente estudio se analizaron los procesos psicológicos asociados con las preferencias de los pacientes con depresión en la toma de decisión sobre su tratamiento psiquiátrico. Participaron 462 pacientes diagnosticados con un trastorno depresivo agudo o recurrente. La mayor parte prefirió asumir un rol colaborativo-pasivo o totalmente pasivo. Los resultados no mostraron diferencias significativas entre pacientes en función de su cronicidad en la preferencia por la toma de decisiones, aunque un mayor tiempo de tratamiento se asoció con un estilo más pasivo. El MANCOVA aplicado al total de participantes, controlando la edad, el nivel educativo y el tiempo de tratamiento, indicó que los pacientes colaborativos y pasivos mostraron mayor locus de control centrado en la confianza en el psiquiatra que los activos. Se encontraron diferencias de género mostrando en los hombres mayor locus de control interno y reactancia psicológica, y en las mujeres, mayor locus centrado en el azar. Los análisis de regresión indicaron que en el caso de los hombres, la preferencia pasiva por la toma de decisión es explicada por el locus centrado en el psiquiatra. Sin embargo, en las mujeres tuvo mayor peso la edad, seguida del locus centrado en el azar, el locus centrado en el psiquiatra y una percepción de menor autoeficacia. Los hallazgos señalan la necesidad de estudiar desde una perspectiva diferencial la participación de los pacientes en la toma de decisión de acuerdo con los procesos psicológicos, así como la repercusión que esta tiene en la adherencia al tratamiento médico.

Neste estudo, analisaram-se os processos psicológicos associados com as preferências dos pacientes com depressão na tomada de decisão sobre seu tratamento psiquiátrico. Participaram 462 pacientes diagnosticados com um transtorno depressivo agudo ou recorrente. A maior parte preferiu assumir um papel colaborativo-passivo ou totalmente passivo. Os resultados não mostraram diferenças significativas entre pacientes em função de sua cronicidade na preferência por tomada de decisões, embora um maior tempo de tratamento tenha sido associado com um estilo mais passivo. O MANCOVA aplicado ao total de participantes, controlando a idade, o nível educativo e o tempo de tratamento, indicou que os pacientes colaborativos e passivos mostraram maior lócus de controle centralizado na confiança no psiquiatra do que os ativos. Constataram-se diferenças de gênero que mostraram nos homens maior lócus de controle interno e reatância psicológica, e, nas mulheres, maior lócus centralizado no aleatório, o lócus centralizado no psiquiatra e uma percepção de menor autoeficácia. Os achados indicam a necessidade de estudar, sob uma perspectiva diferencial, a participação dos pacientes na tomada de decisão de acordo com os processos psicológicos e a repercussão que esta tem na aderência ao tratamento médico.

Puntos de corte de la versión española del Cuestionario de Cualidades y Dificultades (SDQ) / Cutt-offs of the Spanish version of the Strength and Difficulties Questionnaire (SDQ)

INTRODUCCIÓN: El Cuestionario de Cualidades y Dificultades (SDQ) es un instrumento breve de evaluación de trastornos mentales en la infancia y la adolescencia. Ha sido desarrollado en el Instituto de Psiquiatría de Londres en los años 90. Se administra a padres y profesores con una única versión para ambos. Consta de 25 ítems y valora 5 aspectos: hiperactividad, síntomas emocionales, problemas de comportamiento, problemas de relaciones con iguales y conducta prosocial. Su sencilla administración e interpretación lo convierte en una herramienta muy útil en pediatría. Se encuentra traducido y validado en muchos idiomas, incluido el español. Es muy utilizado para estudios epidemiológicos, de despistaje y clínicos. Sus propiedades psicométricas han demostrado ser adecuadas para estos aspectos. MATERIAL Y MÉTODOS: Se recogieron las contestaciones del SDQ de padres y profesores de una muestra comunitaria de 597 niños entre 7 y 10 años, estando igualmente representados ambos sexos. Se realizó el análisis estadístico para identificar los puntos de corte. Para cada escala se determinaron los rangos de normalidad, límite y anormalidad. RESULTADOS: Los resultados obtenidos en la presente investigación revelan unos puntos de corte sensiblemente distintos a los obtenidos para las versiones en otros idiomas distintos al español. CONCLUSIONES: La traducción española se presenta como un instrumento igual de útil que el Cuestionario inglés original y el traducido a otros idiomas

INTRODUCTION: The Strengths and Difficulties Questionnaire (SDQ) was developed by Professor Robert Goodman at the Institute of Psychiatry (UK) in the 1990's. It is a brief behavioural screening instrument internationally used for the screening of mental health problems in children and adolescents. It consists in a 25 item questionnaire with 5 different scales: emotional symptoms, conduct problems, hyperactivity / inattention peer relationship problems and prosocial behaviours. Its simple administration and interpretation has made it a very useful tool in paediatrics. The SDQ has been translated and validated in more than 70 languages, these includes a Spanish version. It is widely used as an adequate tool for epidemiological, early detection and clinical studies, as demonstrated by its psychometric properties. MATERIAL AND METHODS: Parents and teachers ratings of SDQ were collected for a community-based sample of 597 children between 7 and 10 years, in which both genders were equally represented. Statistical evaluation of cutt-offs were performed. Bandings identifying normal, borderline, and clinical ranges were defined for each scale. RESULTS: The present study reveal cut off results sensibly different to those obtained in other languages.CONCLUSIONS: The Spanish translation seems to be a similarly useful tool as the original English and other languages questionnaire

Estrategias de manejo de los antidepresivos desde la perspectiva de los pacientes: luchando interna y externamente / Antidepressant management strategy from the patient perspective: Struggling internally and externally

Objetivo: Identificar la trayectoria de consumo y las estrategias de manejo de los antidepresivos desde la perspectiva de los pacientes. Diseño: Estudio cualitativo. Emplazamiento: Tenerife. Participantes y/o contextos: Muestreo teórico hasta alcanzar la saturación. Método: Se incluyeron 17 entrevistas abiertas a personas que consumían antidepresivos con o sin ansiolíticos. El rango de edad osciló entre 35-85 años, de los cuales 13 eran mujeres. Diez vivían en un contexto más urbano y el resto en zona rural. Las entrevistas se grabaron en audio, fueron transcritas verbatim y analizadas según el método de Grounded Theory modificado con el apoyo del programa ATLAS. ti. Resultados: El proceso identificado de manejo de los antidepresivos se denominó «luchando interna y externamente». Consiste en la evaluación personal de los beneficios y riesgos del consumo del medicamento (lucha interna), frente al estigma y presión ambiental (lucha externa). El resultado del proceso de evaluación que realizan los pacientes puede dar lugar a diferentes estrategias de adaptación al tratamiento farmacológico: «aceptación incondicional», «aceptación resignada» o bien «aceptación forzada». Conclusiones: Entender el proceso de evaluación que el paciente necesita hacer, dada la lucha interna y externa en la que se ve inmerso, es útil para poder realizar intervenciones que mejoren el consumo de medicamentos. De hecho, los médicos tienen un papel muy relevante, aunque no siempre explícitamente buscado, en la resolución del dilema que se plantean los pacientes acerca del consumo de los fármacos antidepresivos; y, por tanto, en la reducción del tiempo de sufrimiento de los pacientes(AU)

Objective: To identify the consumption pathway and strategies of coping with antidepressants use from the patients perspective. Design: Qualitative research. Setting: Tenerife. Sampling: Theoretical sampling until saturation. Method: A total of 17 open interviews with patients who consumed antidepressants whether combined with tranquilisers or not. The age range was between 35-85 years, and there were 13 women. Ten lived in a more urban setting and the rest in rural areas. Interviews were audio-recorded, transcribed verbatim and analysed using a modified Grounded Theory supported by the software program ATLAS. ti. Results: The process identified as coping with antidepressants, was called "struggling internally and externally". It consisted of the individual assessment of the benefits and risks of medication use (internal struggle), addressing stigma and social pressure (external struggle). The outcome of the assessment made by patients may lead to different strategies for adjusting to drug treatment: "unconditional acceptance", "resigned acceptance" or "forced acceptance". Conclusions: Understanding the evaluation process that the patient needs to go through, given the internal and external struggle in which they are immersed, can be useful to develop interventions that improve medication use. In fact, physicians have an important role, although not always explicitly sought in resolving the dilemma posed by patients using antidepressant drugs and, therefore, reducing the length of patient suffering(AU)

[Antidepressant management strategy from the patient perspective: struggling internally and externally]. / Estrategias de manejo de los antidepresivos desde la perspectiva de los pacientes: luchando interna y externamente.

OBJECTIVE: To identify the consumption pathway and strategies of coping with antidepressants use from the patients perspective. DESIGN: Qualitative research. SETTING: Tenerife. SAMPLING: Theoretical sampling until saturation. METHOD: A total of 17 open interviews with patients who consumed antidepressants whether combined with tranquilisers or not. The age range was between 35-85 years, and there were 13 women. Ten lived in a more urban setting and the rest in rural areas. Interviews were audio-recorded, transcribed verbatim and analysed using a modified Grounded Theory supported by the software program ATLAS.ti. RESULTS: The process identified as coping with antidepressants, was called "struggling internally and externally." It consisted of the individual assessment of the benefits and risks of medication use (internal struggle), addressing stigma and social pressure (external struggle). The outcome of the assessment made by patients may lead to different strategies for adjusting to drug treatment: "unconditional acceptance", "resigned acceptance" or "forced acceptance". CONCLUSIONS: Understanding the evaluation process that the patient needs to go through, given the internal and external struggle in which they are immersed, can be useful to develop interventions that improve medication use. In fact, physicians have an important role, although not always explicitly sought in resolving the dilemma posed by patients using antidepressant drugs and, therefore, reducing the length of patient suffering.

The relationship among mental health status (GHQ-12), health related quality of life (EQ-5D) and health-state utilities in a general population.

AIM: To assess the relationship between mental health and health-related quality of life (HRQL) in the general population, and to map GHQ-12 as a screening test for population psychological distress to a generic health state measure (EQ-5D) in order to estimate health state values and allow deriving quality-adjusted life years. METHODS: Relationship between mental health and HRQL was examined from the 2004 Canary Islands' Health Survey. Participants were classified as probable psychiatric cases according to GHQ-12. HRQL was measured by the EQ-5D index. Multivariate lineal regression analysis was used to examine the association between mental health and HRQL adjusting by socio-demographic variables and comorbidities. A multivariate regression model was built from EQ-5D to estimate health states values using GHQ-12 as exposure. RESULTS: EQ-5D index scores decreased as the GHQ-12 scores increased. Clinical and socio-demographic factors influenced HRQL without changing the overall trend for this negative relationship. The regression equation explained 43% of the variance. For estimation of utility scores, the model showed a high predictive capacity, with a mean forecast errors of 16%. CONCLUSIONS: HRQL progressively decreased when the probability of being a psychiatric case increased. Findings enable health state values to be derived from GHQ-12 scores for populations where utilities has not or cannot be measured directly.

Evaluación cualitativa en teledermatología: resultados del proyecto piloto Telemedicina 2000 / Qualitative evaluation in teledermatology: results of the telemedicine 200 pilot project

Introducción: Se ha realizado un estudio prospectivo para evaluar la calidad del intercambio de información y la satisfacción en una consulta de teledermatología entre un hospital comarcal en la isla de El Hierro y un hospital de referencia en la isla de Tenerife. Material y métodos: Se realizaron consultas mediante teledermatología en tiempo real con pacientes que estaban en lista de espera para la consulta convencional. Los pacientes, familiares, técnicos y dermatólogos respondían a un cuestionario con preguntas que intentaban valorar la calidad técnica de la teleconsulta, la calidad en el intercambio de información a través de la teleconsulta, la interacción entre el especialista y paciente, preferencias entre telemedicina y el modelo convencional de consulta y la satisfacción global con el proceso de teleconsulta. Resultados: Casi todos los pacientes (95%) declararon estar dispuestos a repetir la experiencia y a recomendar la telemedicina a otros posibles pacientes. Cuando la alternativa a la teleconsulta era "esperar para ver a un especialista en persona", el 65%de los pacientes prefirieron "usar telemedicina", el 15% manifestó preferir "tener una consulta por telemedicina" a "ver al especialista en persona", mientras que el 55% eran indiferentes ante ambas opciones. En el 48% de las consultas, el médico consideró que no había obtenido la misma calidad de información que hubiera podido obtener en una consulta "cara a cara". Discusión: Los resultados del estudio muestran que los pacientes no constituyen una barrera a la difusión de la actividad asistencial en dermatología a través de telemedicina (AU)