Clinical Decision-Making for Appendectomy in Kosovo: A Conjoint Analysis.

Objective: The objective was to investigate the association of clinical attributes with decision making for performing appendectomy and making preoperative preparations for appendectomy. Method: A conjoint analysis with 17 clinical scenarios was executed with surgeons employed at public hospitals in Kosovo. Setting: The study was conducted at two public hospitals in Kosovo that have benefited from quality-improvement interventions. Participants: The participants included 22 surgeons. Outcome measures: The primary outcome was the overall effect of clinical attributes on the decision to perform appendectomy and make the preoperative preparations for appendectomy. Results: In the regression analyses, several attributes demonstrated statistically significant effects on the clinical decision to perform appendectomy and on the practice of preoperative preparation. Conclusions: We found that several factors influenced the decision to perform appendectomy and the practices for preoperative preparation. Nevertheless, the small sample size limited our efforts to interpret the results. These findings could assist Kosovo in the design and implementation of future similar studies and in fostering quality improvement measures that address clinical decision making and the lack of process standardization in the delivery of surgical care.

Clinical Decision-Making for Heart Failure in Kosovo: A Conjoint Analysis.

BACKGROUND: Heart failure represents a life-threatening progressive condition. Early diagnosis and adherence to clinical guidelines are associated with improved outcomes for patients with heart failure. However, adherence to clinical guidelines remains limited in Kosovo. OBJECTIVE: To assess the clinical decision-making related to heart failure diagnosis by evaluating clinicians' preferences for clinical attributes. METHOD: Conjoint analysis with 33 clinical scenarios with physicians employed in public hospitals in Kosovo. SETTING: Two public hospitals in Kosovo that benefited from quality improvement intervention. PARTICIPANTS: 14 physicians (internists and cardiologists) in two hospitals in Kosovo. OUTCOME MEASURES: The primary outcome was the overall effect of clinical attributes on the decision for heart failure diagnosis. RESULTS: When considering clinical signs, the likelihood of a heart failure diagnosis increased for ages between 60 to 69 years old (RRR, 1.88; CI 95%, 1.05-3.34) and a stable heart rate (RRR, 1.93; CI 95%, 1.05-3.55) and decreased for the presence of edema (RRR, 0.23; CI 95%, 0.15-0.36), orthopnea (RRR, 0.31; CI 95%, 0.20-0.48), and unusual fatigue (RRR, 0.61; CI 95%, 0.39-0.94). When considering clinical examination findings, the likelihood for heart failure diagnosis decreased for high jugular venous pressure (RRR, 0.49; CI 95%, 0.32-0.76), pleural effusion (RRR, 0.35; CI 95%, 0.23-0.54), hearing third heart sound, (RRR, 0.50; CI 95%, 0.33-0.77), heart murmur (RRR, 0.57; CI 95%, 0.37-0.88), troponin levels (RRR, 0.59; CI 95%, 0.38-0.91), and NTproBNP levels (RRR, 0.36; CI 95%, 0.24-0.56). CONCLUSIONS: We often found odd and wide variations of clinical signs and examination results influencing the decision to diagnose a person with heart failure. It will be important to explore and understand these results better. The study findings are important for existing quality improvement support efforts and contribute to the standardization of clinical decision-making in the public hospitals in the country. This experience and this study can provide valuable impetus for further examination of these efforts and informing policy and development efforts in the standardization of care in the country.

Telemonitoring in Chronic Obstructive Pulmonary Disease (CHROMED). A Randomized Clinical Trial.

RATIONALE: Early detection of chronic obstructive pulmonary disease (COPD) exacerbations using telemonitoring of physiological variables might reduce the frequency of hospitalization. OBJECTIVES: To evaluate the efficacy of home monitoring of lung mechanics by the forced oscillation technique and cardiac parameters in older patients with COPD and comorbidities. METHODS: This multicenter, randomized clinical trial recruited 312 patients with Global Initiative for Chronic Obstructive Lung Disease grades II to IV COPD (median age, 71 yr [interquartile range, 66-76 yr]; 49.6% grade II, 50.4% grades III-IV), with a history of exacerbation in the previous year and at least one nonpulmonary comorbidity. Patients were randomized to usual care (n = 158) or telemonitoring (n = 154) and followed for 9 months. All telemonitoring patients self-assessed lung mechanics daily, and in a subgroup with congestive heart failure (n = 37) cardiac parameters were also monitored. An algorithm identified deterioration, triggering a telephone contact to determine appropriate interventions. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were time to first hospitalization (TTFH) and change in the EuroQoL EQ-5D utility index score. Secondary outcomes included: rate of antibiotic/corticosteroid prescription; hospitalization; the COPD Assessment Tool, Patient Health Questionnaire-9, and Minnesota Living with Heart Failure questionnaire scores; quality-adjusted life years; and healthcare costs. Telemonitoring did not affect TTFH, EQ-5D utility index score, antibiotic prescriptions, hospitalization rate, or questionnaire scores. In an exploratory analysis, telemedicine was associated with fewer repeat hospitalizations (-54%; P = 0.017). CONCLUSIONS: In older patients with COPD and comorbidities, remote monitoring of lung function by forced oscillation technique and cardiac parameters did not change TTFH and EQ-5D. Clinical trial registered with www.clinicaltrials.gov (NCT 01960907).

Nine differentially expressed genes from a post mortem study and their association with suicidal status in a sample of suicide completers, attempters and controls.

Several lines of evidence indicate that suicidal behaviour is partly heritable, with multiple genes implicated in its aetiology. We focused on nine genes (S100A13, EFEMP1, PCDHB5, PDGFRB, CDCA7L, SCN2B, PTPRR, MLC1 and ZFP36) which we previously detected as differentially expressed in the cortex of suicide victims compared to controls. We investigated 84 variants within these genes in 495 suicidal subjects (299 completers and 196 attempters) and 1513 controls (109 post-mortem and 1404 healthy). We evaluated associations with: 1) suicidal phenotype; 2) possible endophenotypes for suicidal behaviour. Overall positive results did not survive the correction threshold. However, we found a nominally different distribution of EFEMP1 genotypes, alleles and haplotypes between suicidal subjects and controls, results that were partially replicated when we separately considered the subgroup of suicide completers and post-mortem controls. A weaker association emerged also for PTPRR. Both EFEMP1 and PTPRR genes were also related to possible endophenotypes for suicidal behaviour such as anger, depression-anxiety and fatigue. Because of the large number of analyses performed and the low significance values further replication are mandatory. Nevertheless, neurotrophic gene variants, in particular EFEMP1 and PTPRR, may have a role in the pathogenesis of suicidal behaviour.

Health care reforms.

In large systems, such as health care, reforms are underway constantly. The article presents a definition of health care reform and factors that influence its success. The factors being discussed range from knowledgeable personnel, the role of involvement of international experts and all stakeholders in the country, the importance of electoral mandate and governmental support, leadership and clear and transparent communication. The goals set need to be clear, and it is helpful to have good data and analytical support in the process. Despite all debates and experiences, it is impossible to clearly define the best approach to tackle health care reform due to a different configuration of governance structure, political will and state of the economy in a country.

Constructing a coronary scale for ischemic heart disease: case-control study.

AIM: To develop a scale measuring proneness to ischemic heart disease. METHODS: Ischemic heart disease was angiographically documented in 187 men. In 187 matched controls the diagnosis of ischemic heart disease was ruled out by examination of medical records and history data, and when necessary, clinical examination and specialized diagnostic procedures. Item analysis of the Eysenck Personality Questionnaire (EPQ) was performed on 100 men with ischemic heart disease and their male controls, and then a replication study was performed on the remaining 87 pairs. RESULTS: A Coronary Scale was constructed from 8 EPQ items significantly and consistently different between the groups. Most of these items were drawn from the neuroticism scale. The Coronary Scale yielded significant correlations with emotionally saturated psychological variables. CONCLUSION: Coronary Scale may be useful in everyday practice to select patients with ischemic heart disease and those who are at higher risk to develop disease. It could be used for detecting a high-risk group of emotionally labile subjects to concentrate efforts for prevention of coronary disease.