An estimate of the need for continuous glucose monitoring in type 2 diabetes with intensive insulin treatment in secondary healthcare.

AIM: To estimate the proportion of persons with type 2 diabetes (T2DM) receiving intensive insulin treatment in the secondary healthcare who could be candidates for continuous glucose monitoring (CGM), based on different HbA1c criteria. For comparison, the results are also presented as proportion of persons with type 1 diabetes (T1DM) in the same region. PATIENTS AND METHODS: In the Central Denmark Region, we identified all persons with T1DM (n = 6179) and T2DM (n = 4315) who had a minimum of one contact to a diabetes outpatient clinic from September 2021 to September 2022. Insulin regimen and HbA1c measured after a minimum of 2 months with a stable insulin regimen were retrieved from the healthcare administrative electronic platform used in the region. RESULTS: The numbers of persons with T1DM and T2DM with HbA1c meeting the criteria were 5145 and 3090, respectively. The fraction of T2DM with basal-bolus insulin was 35.3%, and the fraction with basal-bolus insulin and HbA1c >53 (7%) mmol/mol or >58 (7.5%) mmol/mol was 20.5% and 16.6%, respectively. These proportions correspond to 19.4%, 14.4% and 11.7% of the persons with T1DM in the same geographical area. CONCLUSION: The proportion of persons with T2DM in secondary healthcare undergoing intensive insulin treatment who could be candidates for CGM corresponded to only a minor fraction of persons with T1DM in the same region, irrespective of any HbA1c criteria applied.

Military veterans and civilians' mental health diagnoses: an analysis of secondary mental health services.

PURPOSE: Healthcare provision in the United Kingdom (UK) falls primarily to the National Health Service (NHS) which is free at the point of access. In the UK, there is currently no national marker to identify military veterans in electronic health records, nor a requirement to record it. This study aimed to compare the sociodemographic characteristics and recorded mental health diagnoses of a sample of veterans and civilians accessing secondary mental health services. METHODS: The Military Service Identification Tool, a machine learning computer tool, was employed to identify veterans and civilians from electronic health records. This study compared the sociodemographic characteristics and recorded mental health diagnoses of veterans and civilians accessing secondary mental health care from South London and Maudsley NHS Foundation Trust, UK. Data from 2,576 patients were analysed; 1288 civilians and 1288 veterans matched on age and gender. RESULTS: Depressive disorder was the most prevalent across both groups in the sample (26.2% veterans, 15.5% civilians). The present sample of veterans accessing support for mental health conditions were significantly more likely to have diagnoses of anxiety, depressive, psychosis, personality, and stress disorders (AORs ranging 1.41-2.84) but less likely to have a drug disorder (AOR = 0.51) than age- and gender-matched civilians. CONCLUSION: Veterans accessing secondary mental health services in South London had higher risks for many mental health problems than civilians accessing the same services. Findings suggest that military career history is a key consideration for probable prognosis and treatment, but this needs corroborating in other geographical areas including national population-based studies in the UK.

Shifting risk-stratified early prostate cancer detection to a primary healthcare setting.

OBJECTIVE: To evaluate the feasibility of multivariable risk stratification for early prostate cancer (PCa) detection in a primary healthcare diagnostic facility with regard to its effects on the referral rate and subsequent PCa diagnoses compared to a PSA threshold of 3.0 ng/mL as the current referral indicator. PATIENTS AND METHODS: In 2014, the Erasmus MC Cancer Institute and the primary healthcare diagnostic facility STAR-SHL (located in Rotterdam city centre) initiated this observational study, in which general practitioners (GPs) could refer men who wished to undergo PCa screening to STAR-SHL for consultation by specially trained personnel. Referral recommendations to secondary healthcare were based on the outcome of application of the Rotterdam Prostate Cancer Risk Calculator (RPCRC) and were compared to the current Dutch GPs' PSA referral threshold of 3.0 ng/mL. For data collection on PCa diagnoses, the study cohort was linked to the Dutch nationwide pathology databank (PALGA). RESULTS: Between January 2014 and February 2021, 507 men were referred for consultation and in 495 men prostate-specific antigen (PSA) was tested. The median (interquartile range) follow-up from consultation to PALGA linkage was 43 (25-65) months. In total, 279 men (56%) had a PSA level ≥3.0 ng/mL, of whom 68% (95% confidence interval [95% CI] 63-74) were considered at low risk according to the RPCRC. Within 1 year after consultation, one of these men (0.52%; 95% CI 0.092-2.9) was diagnosed with clinically significant (cs)PCa (i.e., International Society of Urological Pathology Grade Group ≥2). Thereafter, another four (2.1%; 95% CI 0.82-5.3) low-risk men were diagnosed with csPCa. Of the high-risk men who were biopsied within 1 year after consultation (n = 61), 77% (95% CI 65-86) were diagnosed with PCa and 49% (95% CI 37-61) with csPCa. CONCLUSION: In a primary healthcare diagnostic facility, the RPCRC could reduce up to 68% of referrals to secondary healthcare, as compared to a PSA referral threshold of 3.0 ng/mL. Deploying the RPCRC in this setting resulted in a high csPCa detection rate in those men biopsied. This strategy can be considered safe since the observational data showed low proportions of csPCa among men at low risk.

Social and spatial inequalities in healthcare use among people living with dementia in England (2002-2016).

OBJECTIVES: Healthcare services for people living with dementia (PLWD) are stretched, and government promises of increased funding remain undelivered. With the UK dementia population to surpass 1 million by 2024, and dementia care costs predicted to almost treble by 2040, it is essential we understand differences in healthcare use among PLWD. This study aimed to explore social and spatial variations in healthcare use among people diagnosed with dementia (2002-2016). METHODS: Data were derived from Electronic Health Records of Clinical Practice Research Datalink GP patients in England (n = 142,302). To standardise healthcare contacts, rates of healthcare contacts per year were calculated for three primary (GP observations and medications) and three secondary healthcare types [Accident & Emergency (A&E) attendances and, emergency and elective hospital admissions]. Fully-adjusted generalised linear regression models were used to identify healthcare use variation by social and spatial groups. Twelve models were generated, one for each healthcare type in early- and late-onset populations separately. RESULTS: This study highlights numerous social and spatial variations in healthcare use among PLWD. Among PLWD, several groups tended to have healthcare service use more closely associated with negative outcomes, including a greater likelihood of A&E attendances and emergency and elective hospital admissions. These groups include: men, people from White ethnicity groups and people from more deprived and rural areas. CONCLUSIONS: Systemic and social measures are needed to reduce variations in healthcare use inequalities in PWLD. These include greater healthcare continuity, health checks and medicines reviews, culturally appropriate services, better and more accessible treatment and improved infrastructure.

The burden of selected vaccine-preventable diseases on the secondary care health system in England: Results from a five-year administrative healthcare dataset.

OBJECTIVES: This study examined healthcare resource use (HCRU) for selected vaccine-preventable diseases (VPD) in secondary care in England. METHODS: The hospital episode statistics (HES) dataset covering all secondary care interactions within the English National Health Service (NHS) from 2015 to 2021 was used to identify and track HCRU for patients with a primary or secondary diagnosis for pertussis and Haemophilus influenzae type b (Hib), or a primary diagnosis only for hepatitis B, diphtheria, poliomyelitis, or tetanus. The first documented diagnosis during the study period (01/04/2015-31/03/2021) was the index event. RESULTS: 7,274 patients with a total of 5,554,343 patient-days (mean follow up 1,491 days) were included. The total number of hospital admissions was 27,092 and total inpatient cost was £4,987,770, with hepatitis B making up ∼80 % of this. Mean outpatient hospital appointments per patient were highest for tetanus (4.00), but total outpatient A&E cost burden was highest for Hib (£643,343 [mean per attendance £144.57]). For patients 0-9 years of age (n = 1,917), pertussis (n = 1,547) and Hib (n = 313) were by far the most commonly coded diseases. Hepatitis B was the most common disease in adults of working age and Hib was most prevalent in adults of retirement age. Surprisingly, poliomyelitis was observed in the database potentially due to historic diagnoses and/or coding inaccuracy. Other discrepancies with surveillance data were noted. CONCLUSIONS: VPDs impose a large burden on the NHS, but there is potential to reduce this and improve public health by optimising vaccination schedules, improving access and ensuring high coverage rates.

A Secondary-Primary Mental Health Integrated Care Model for Communities with Diverse Population and Complex Health Needs - a Case Study with Health Care Utilization Evaluation.

Integrated care is expected to improve patient experience, patient outcomes and assist with the increasing demand on health services from those with long term conditions including mental disorder. Few studies have evaluated health care utilization as a consequence of increased integration of mental health care. This study considers the factors known to influence secondary health service utilization and investigated the impact of a locality based mental health integrated model of care (ILoC) providing specialist consultation and liaison advice to primary care, to support early diagnosis and treatment. Using existing hospital databases, the study-cohort was identified (service users supported by ILoC, and then referred within 6 months to specialist mental health services (MHS) care between 2017- 2018) and compared on health services utilization with a matched-cohort (without ILoC support before referral to specialist services). The length-of-care in the non-acute MHS was 71% shorter for the ILoC study-cohort, and differences increased in the subgroup taking antidepressants. The ILoC study-cohort was less likely to be admitted to acute MHS on first referral post ILoC intervention and had a 25% lower relative risk of acute MHS admissions at any time in follow-up. There was no difference in the average MHS inpatient length-of-stay. The risk of general hospital acute inpatient admission was marginally higher in the ILoC study-cohort. Conclusions: ILoC appears to shorten non-acute length-of-specialist-care and reduce acute mental health admission. The study provides a first step in understanding the clinical characteristics and specialist services health-care utilization of patients supported by an integrated mental care approach.

Early evidence and lessons learnt from an NHS Wales Video Consulting Service.

Background: The use of video consulting (VC) in Wales, United Kingdom (UK) has expanded rapidly during the COVID-19 pandemic. Traditionally, VC has been the subject of small-scale projects and evaluations. In response to the pandemic emergency, there was an opportunity to roll out and evaluate VC on a larger and more representative scale, across a wider range of National Health Service (NHS) specialities.Aims: This paper presents an overview of a dataset captured by the 'The NHS Wales VC Service'. The purpose of this study was to capture perspectives of healthcare professionals only (including clinicians, administration and management) on the use of VC and explore lessons learnt from the national implementation process.Methodology: Using an online, mixed methods retrospective survey capturing descriptive and narrative data.Results: A total of 1256 NHS healthcare professionals shared their VC experience. Overall, responses were positive, and healthcare professionals expressed optimistic views regarding the use, value and benefit of VC, even when faced with challenges on occasions.Conclusions: A lesson learnt, is that difference occurs in innovation, even in a small country like Wales, yet it is not necessarily a negative outcome, but rather, respecting and incorporating difference, can improve long-term sustainability.

Changes in Secondary Healthcare Use Over Retirement Transition: Examining Social Differences With Swedish Register Data.

Background: Despite its relevance for healthcare expenditures and public health, few studies have examined how secondary healthcare use changes during the retirement transition. We therefore use Swedish register data to examine whether retirement is associated with intensified secondary healthcare use overall and for specific subgroups based on gender and education. Methods: The sample was all individuals registered in Sweden who retired from paid work in 2010. We used Generalised Estimating Equations models to analyse changes in two indicators of secondary healthcare use, namely specialist visits and hospitalisation, from 3 years prior to 5 years after retirement. Results: Retirement is not associated with changes in specialist visits or hospitalisation per se. Three years before retirement, women were more likely to visit a specialist but less likely to be hospitalised than men; these gender differences disappeared approximately 1 year before retirement. Women with high education were more likely to visit a specialist than women with low education across the entire retirement transition, particularly post-retirement. Significant differences with regard to specialist visits between male educational groups only emerged 12 months after retirement. There were no educational differences with regard to hospitalisation. Conclusions: We conclude that secondary healthcare use in Sweden does not generally change with retirement. However, over the course of retirement gender differences in secondary healthcare use tend to decrease and within-gender educational differences tend to increase. We interpret the results as reflecting the role of labour market institutions in contributing to gender differences but repressing educational differences in secondary healthcare use.

The barriers and facilitators of radical innovation implementation in secondary healthcare: a systematic review.

PURPOSE: This study aimed to identify the barriers and facilitators related to the implementation of radical innovations in secondary healthcare. DESIGN/METHODOLOGY/APPROACH: A systematic review was conducted and presented in accordance with a PRISMA flowchart. The databases PubMed and Web of Science were searched for original publications in English between the 1st of January 2010 and 6th of November 2020. The level of radicalness was determined based on five characteristics of radical innovations. The level of evidence was classified according to the level of evidence scale of the University of Oxford. The Consolidated Framework for Implementation Research was used as a framework to classify the barriers and facilitators. FINDINGS: Based on the inclusion and exclusion criteria, nine publications were included, concerning six technological, two organizational and one treatment innovation. The main barriers for radical innovation implementation in secondary healthcare were lack of human, material and financial resources, and lack of integration and organizational readiness. The main facilitators included a supportive culture, sufficient training, education and knowledge, and recognition of the expected added value. ORIGINALITY/VALUE: To our knowledge, this is the first systematic review examining the barriers and facilitators of radical innovation implementation in secondary healthcare. To ease radical innovation implementation, alternative performance systems may be helpful, including the following prerequisites: (1) Money, (2) Added value, (3) Timely knowledge and integration, (4) Culture, and (5) Human resources (MATCH). This study highlights the need for more high-level evidence studies in this area.

Risk Perception and Psychological Impact of COVID-19 Pandemic Among Healthcare Workers in Primary and Secondary Healthcare Settings in Qatar: A National Study.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, primary and secondary healthcare workers (HCWs) have faced unprecedented stress, jeopardizing their mental well-being. AIMS: To compare risk perception and psychological distress between primary and secondary HCWs. METHOD: A cross-sectional web-based survey was conducted with HCWs in Qatar from April 5 to July 5, 2020. Psychological distress and risk perception were assessed using the Kessler Psychological Distress Scale, a perceived COVID-19 risk questionnaire, and a sociodemographic questionnaire. RESULTS: Of the 4417 participating HCWs, 3421 (90.3%) felt that their job increased their risk of COVID-19 exposure, 3759 (90.9%) accepted this as part of their job, and 3440 worried that this also increased the risk of exposure to their families. Moreover, 2911 (84.8%) believed that their employer would look after their needs if they contracted COVID-19. Moderate to severe psychological distress was present in 1346 (30.5%) HCWs. Primary HCWs were less likely to experience moderate to severe psychological distress than secondary HCWs (adjusted OR, 0.48; 95% CI 0.29-0.77, P = .003). Secondary HCWs who worked in COVID-19 designated areas had greater psychological distress. CONCLUSIONS: HCWs' exposure to outbreaks has various psychological effects, which may have long-term consequences and affect their decision-making capacity. Strategies to enhance the mental well-being of HCWs exposed to COVID-19 should be introduced immediately.

Caesarean delivery rate and indications at a secondary healthcare Facility in Ibadan, South Western Nigeria: a five-year review.

BACKGROUND: Caesarean delivery is an essential surgical skill within the primary care setting aimed at reducing maternal morbidity and mortality. OBJECTIVES: To determine the rate and indications for caesarean deliveries with a view to improving on the service delivery in the study area. METHODS: A retrospective review of all caesarean deliveries over a five-year period, January 1st, 2012 to December 31st, 2016. RESULTS: A total of 2321 deliveries were recorded during the study duration and 481 of them were through caesarean section (CS) giving a caesarean section rate of 20.4%. The rate was higher in the multigravida 255 (53.1%). The commonest indication for caesarean section was previous caesarean section 131 (27.2%). Emergency caesarean delivery accounted for 278 (57.8%). Only 16 (3.3%) stayed more than five days postoperatively while the rest, 465 (96.7%), stayed less than five days. There was a gradual yearly increase in rate from 12.1% in 2012 to 19.5% in 2016. CONCLUSION: The rate of CS in this study has shown a gradual yearly increase with emergency CS having a higher percentage. Early diagnosis and referral of high-risk pregnancies from peripheral hospitals could reduce emergency CS among the study population.

Seasonality of adult fragility fractures and association with weather: 12-year experience of a UK Fracture Liaison Service.

PURPOSE: To investigate the monthly and seasonal variation in adult osteoporotic fragility fractures and the association with weather. METHODS: 12-year observational study of a UK Fracture Liaison Service (outpatient secondary care setting). Database analyses of the records of adult outpatients aged 50 years and older with fragility fractures. Weather data were obtained from the UK's national Meteorological Office. In the seasonality analyses, we tested for the association between months and seasons (determinants), respectively, and outpatient attendances, by analysis of variance (ANOVA) and Tukey's test. In the meteorological analyses, the determinants were mean temperature, mean daily maximum and minimum temperature, number of days of rain, total rainfall and number of days of frost, per month, respectively. We explored the association of each meteorological variable with outpatient attendances, by regression models. RESULTS: The Fracture Liaison Service recorded 25,454 fragility fractures. We found significant monthly and seasonal variation in attendances for fractures of the: radius or ulna; humerus; ankle, foot, tibia or fibula (ANOVA, all p-values <0.05). Fractures of the radius or ulna and humerus peaked in December and winter. Fractures of the ankle, foot, tibia or fibula peaked in July, August and summer. U-shaped associations were showed between each temperature parameter and fractures. Days of frost were directly associated with fractures of the radius or ulna (p-value <0.001) and humerus (p-value 0.002). CONCLUSION: Different types of fragility fractures present different seasonal patterns. Weather may modulate their seasonality and consequent healthcare utilisation.

The impact of lockdown during the COVID-19 pandemic on osteoporotic fragility fractures: an observational study.

We investigated whether osteoporotic fractures declined during lockdown, among adults aged 50 years and older. We showed that fewer outpatients attended the Fracture Clinic, for non-hip fractures, during lockdown; in contrast, no change in admissions for hip fractures was observed. This could be due to fewer outdoors falls, during lockdown. PURPOSE: Many countries implemented a lockdown to control the spread of the COVID-19 pandemic. We explored whether outpatient attendances to the Fracture Clinic for non-hip fragility fracture and inpatient admissions for hip fracture declined during lockdown, among adults aged 50 years and older, in a large secondary care hospital. METHODS: In our observational study, we analysed the records of 6681 outpatients attending the Fracture Clinic, for non-hip fragility fractures, and those of 1752 inpatients, admitted for hip fracture, during the time frames of interest. These were weeks 1st to 12th in 2020 ("prior to lockdown"), weeks 13th to 19th in 2020 ("lockdown") and corresponding periods over 2015 to 2019. We tested for differences in mean numbers (standard deviation (SD)) of outpatients and inpatients, respectively, per week, during the time frames of interest, across the years. RESULTS: Prior to lockdown, in 2020, 63.1 (SD 12.6) outpatients per week attended the Fracture Clinic, similar to previous years (p value 0.338). During lockdown, 26.0 (SD 7.3) outpatients per week attended the Fracture Clinic, fewer than previous years (p value < 0.001); similar findings were observed in both sexes and age groups (all p values < 0.001). During lockdown, 16.1 (SD 5.6) inpatients per week were admitted for hip fracture, similar to previous years (p value 0.776). CONCLUSION: During lockdown, fewer outpatients attended the Fracture Clinic, for non-hip fragility fractures, while no change in inpatient admissions for hip fracture was observed. This could reflect fewer non-hip fractures and may inform allocation of resources during pandemic.

Quantifying the direct secondary health care cost of seasonal influenza in England.

BACKGROUND: The winter pressure often experienced by NHS hospitals in England is considerably contributed to by severe cases of seasonal influenza resulting in hospitalisation. The prevention planning and commissioning of the influenza vaccination programme in the UK does not always involve those who control the hospital budget. The objective of this study was to describe the direct medical costs of secondary care influenza-related hospital admissions across different age groups in England during two consecutive influenza seasons. METHODS: The number of hospital admissions, length of stay, and associated costs were quantified as well as determining the primary costs of influenza-related hospitalisations. Data were extracted from the Hospital Episode Statistics (HES) database between September 2017 to March 2018 and September 2018 to March 2019 in order to incorporate the annual influenza seasons. The use of international classification of disease (ICD)-10 codes were used to identify relevant influenza hospitalisations. Healthcare Resource Group (HRG) codes were used to determine the costs of influenza-related hospitalisations. RESULTS: During the 2017/18 and 2018/19 seasons there were 46,215 and 39,670 influenza-related hospital admissions respectively. This resulted in a hospital cost of £128,153,810 and £99,565,310 across both seasons. Results showed that those in the 65+ year group were associated with the highest hospitalisation costs and proportion of in-hospital deaths. In both influenza seasons, the HRG code WJ06 (Sepsis without Interventions) was found to be associated with the longest average length of stay and cost per admission, whereas PD14 (Paediatric Lower Respiratory Tract Disorders without Acute Bronchiolitis) had the shortest length of stay. CONCLUSION: This study has shown that influenza-related hospital admissions had a considerable impact on the secondary healthcare system during the 2017/18 and 2018/19 influenza seasons, before taking into account its impact on primary health care.

Perfil clínico e epidemiológico dos pacientes em uso de terapia biológica em uma policlínica universitária do Rio de Janeiro: um estudo descritivo / Clinical and epidemiological profile of patients using biological therapy in a university polyclinic in Rio de Janeiro: a descriptive study / Perfil clínico y epidemiológico de los pacientes que utilizan terapia biológica en un policlínico universitário de Rio de Janeiro: un estudio descriptivo

OBJETIVO: descrever o perfil socioeconômico, demográfico e as condições clínicas dos pacientes em uso de terapia biológica em uma unidade de saúde de atenção secundária do município do Rio de Janeiro. MÉTODO: estudo descritivo, transversal com abordagem quantitativa. RESULTADOS: A maioria dos pacientes eram do sexo feminino, com idade ≥50 anos, pardos, casados ou convivendo com parceiro, sem filhos e com ensino médio completo. Declararam-se 28,75% inválidos e possuírem como principal fonte de renda, o beneficio de seguridade social a pensão do Instituto Nacional do Seguro Social com valor entre 1-2 salários mínimos e contribuírem permanentemente com a renda da família com a qual residem. Quanto às características clínicas, 54% relataram realizar acompanhamento no ambulatório de gastroenterologia, 55% fazerem uso de Infleximabe e estarem em tratamento a mais de 24 meses. CONCLUSÃO: A partir do conhecimento das características dessa clientela podemos proporcionar um apoio organizacional de prestação de cuidados que influenciará diretamente a qualidade e a satisfação dos pacientes e profissionais.

OBJECTIVE: to describe the socioeconomic, demographic and clinical conditions of patients on biological therapy in a secondary health care unit in the city of Rio de Janeiro. METHOD: a descriptive, cross-sectional study with a quantitative approach. RESULTS: Most patients were female, aged ≥50 years, brown-skinned, married or living with a partner, without children and having concluded high school. 28.75% were declared disabled and had as their main source of income the social security pension from the National Institute of Social Security, amounting between 1 and 2 minimum wages, all of them contributing permanently to the total income of the families they were living with. As for clinical characteristics, 54% reported being followed up at the gastroenterology clinic, 55% of them taking Infleximab and having been on treatment for more than 24 months. CONCLUSION: Based on the knowledge of the characteristics of this clientele, we can provide an organizational support to the provision of care that may have direct influence on the quality of life and well-being of patients and professionals.

OBJETIVO: describir el perfil socioeconómico, demográfico y las condiciones clínicas de los pacientes que utilizan terapia biológica en una unidad de salud de atención secundária en la municipalidad de Rio de Janeiro. MÉTODO: estudio descriptivo, transversal con abordage cuantitativo. RESULTADOS: La mayoría de los pacientes era del sexo femenino, con edad ≥50 AÑOS, morenos, casados o viviendo con pareja, sin hijos y con escuela secundaria completa. 28,75% declaran que son discapacitados y que su principal fuente de ingreso es la pensión que reciben del Instituto Nacional de Seguridad Social con valor entre 1 y 2 salarios mínimos, contribuyendo de manera permanente al ingreso de la família con la cual viven. En cuanto a las características clínicas, 54% reportaron usar Infleximabe y estar en tratamiento hace más de 24 meses. CONCLUSIÓN: A partir del conococimiento de las caracteristicas de esa clientela se puede aportar un apoyo organizativo a la prestación de cuidados, que impactará directamente la calidad de vida y la satisfacción de pacientes y profesionales.

Attitudes and knowledge regarding referrals for bariatric surgery among Danish secondary healthcare providers: A national survey.

Bariatric surgery induces significant and sustained weight loss and subsequently reduces obesity-related comorbidities. However, only a small percentage of patients with severe obesity undergo bariatric surgery in Denmark. There is limited knowledge about the experiences with and possible reservations to bariatric surgery among secondary healthcare providers. The aim of this cross-sectional study was to investigate referral patterns and knowledge regarding the criteria for bariatric surgery among Danish secondary healthcare providers, treating obesity-related diseases. A questionnaire regarding experiences with and reservations to referring patients for consideration for bariatric surgery, along with thoughts to specific patient cases were sent to several specialists: endocrinologists, obstetricians and gynaecologists, orthopaedic surgeons and otorhinolaryngologists. Most questions required responses on a 5-point Likert scale and frequency distributions were calculated. A total of 345 (44%) specialists responded to the questionnaires. Good knowledge of the criteria for referral to bariatric surgery varied among the specialist from 6% to 68%. One of the main issues was a concern about the medical and surgical postoperative complications, which was a barrier to and influenced referral decisions. Furthermore, specialists were more likely to refer patients to bariatric surgery when patients requested this. Except for endocrinologists, the Danish secondary healthcare specialists interviewed have limited knowledge about bariatric surgery, which results in a reluctance in referring patients. Our results indicate that there is a need to improve knowledge among specialists, regarding the indications, criteria and outcomes for bariatric surgery to establish a more pro-active, specialist led approach to referrals.

Understanding healthcare self-referral in Nigeria from the service users' perspective: a qualitative study of Niger state.

BACKGROUND: The by-pass of the primary level of care to the referral facilities has continued to raise concerns for the healthcare delivery system. About 60-90% of patients in Nigeria are reported to self-refer to a referral level of care. Thus, this study sought to identify the factors that influence service-users' decision to self-refer to the secondary healthcare facilities in Nigeria by exploring the perceptions and experiences of the service-users. METHODS: Twenty-four self-referred service-users were interviewed from three selected secondary healthcare facilities (general hospitals) in Niger state, Nigeria. The interviews were tape-recorded, each lasting 20 min on average. This was subsequently transcribed and framework analysis was employed for the analysis. RESULTS: Various reasons were identified to have resulted in the bypass of the primary healthcare facilities in favour of the secondary level of care. The identified themes were organised based on the predisposing, enabling and need component of Andersen's model. These themes included: patients understanding of the healthcare delivery system; perceptions about the healthcare providers; perceptions about healthcare equipment/ facilities; advice from relatives and friends; service-users' expectations; access to healthcare facilities; regulations/ policies; medical symptoms; perceptions of severity of medical symptoms. CONCLUSIONS: The findings from this study call for an evaluation of the current healthcare referral system, particularly in developing settings like Nigeria and consequently the need for developing a contextual model as applicable to individual settings. Therefore, a multifaceted approach is needed to address the current concerns to ensure patients utilise the appropriate level of care. This will ensure the primary healthcare facilities are not undermined and allow the referral levels of care to live up to their mandate.

TREATMENT RESPONSE IN ADULT PATIENTS WITH HYPERTENSION ATTENDING A SECONDARY HEALTH CARE CENTER IN SOUTH-WEST NIGERIA.

BACKGROUND: There has been an increase in prevalence of hypertension worldwide and a trend towards poor control of hypertension. Despite the development of new guidelines on management of hypertension, it remains a difficult disease to control. METHODS: The study was a prospective cohort study of 386 patients aged 18 to 70 years with uncontrolled hypertension. A simple random sampling technique with computer generated random numbers was used for selection. RESULTS: Majority (58.3%) of the respondents who were overweight had diastolic blood pressure of less than 100 mmHg while 55 (41.7%) respondents who were overweight had diastolic blood pressure of 100mmHg to 110mmHg. Forty (42.1%) of the respondents who were obese had diastolic blood pressure of less than 100mmHg while 55 (57.9%) respondents who were obese had diastolic blood pressure of 100mmHg to 110mmHg. The association was statistically significant (χ2 = 9.845, p-value = 0.02). There was a significant difference between the mean first Systolic Blood pressure and the mean third systolic blood pressure. (< 0.001, 95% CI 19.01- 23.04). Also there was a significant difference between the mean first Diastolic Blood pressure and the mean third Diastolic Blood pressure. (p < 0.001, 95% CI 11.13-11.56). CONCLUSION: This study has shown that increasing body weight was associated with high blood pressures and health education on management of hypertension had significant effect in reducing blood pressures and subsequently leading to better control of hypertension.

Barriers to cardiovascular disease secondary prevention care in the West Bank, Palestine - a health professional perspective.

BACKGROUND: Non-communicable diseases (NCDs) - including cardiovascular disease (CVD), cancer and diabetes - have become a significant global burden on health. Particularly concerning are CVD rates, causing approximately 18 million deaths worldwide every year. The statistics show that the disease is no longer a predominantly high-income country phenomenon, but affects, increasingly, countries in both developing regions and conflict-affected areas. In the occupied Palestinian territory (oPt), the focus of this article, CVD ranks top of ten NCD killers, accounting for approximately 37.6% of deaths. Key risk factors discerned in primary care settings have been related to both structural determinants (i.e. the Israeli occupation) and individual behavioural factors. Unfortunately, no data are available for secondary care settings in the region and, consequently, little is known about patients and their capacity for risk factor behaviour change to manage their CVD.To begin closing this gap in knowledge, our study provides insight into cardiovascular disease secondary prevention care with the overall aim to enhance the understanding of the complexities of managing NCDs like CVD in conflict-affected settings. Specifically, research was carried out among Palestinian health professionals who specialise in coronary artery disease in the West Bank to elicit their views on (a) how socio-political, health system and individual behavioural factors might hinder patients to change their health behaviour and impact on the provision of healthcare and (b) possible solutions for overcoming identified barriers to behaviour change on societal as well as individual-patient levels within secondary care provision in a context of protracted conflict. METHODS: This study is based on a qualitative approach in order to provide more in-depth information about health beliefs and behaviours, experiences and views of health professionals with regards to CVD secondary care. In total, 12 semi-structured interviews were conducted among doctors providing treatment to patients with CVD in secondary care settings. Interviews focused on health professionals' perspectives on risk factors and perceived barriers to behaviour change among known CVD patients receiving secondary care. Interviewees were also asked to propose possible actions that could be taken to overcome the identified barriers at both societal and individual patient levels. All interviews were digitally recorded, transcribed and analysed using thematic analysis. RESULTS: Study results confirmed our prior theory of the complex entanglement of socio-political, health system and individual-level factors with regards to CVD experience, health-seeking and treatment. Also confirmed was our assumption that it is crucial to understand experts' definitions and approaches to treatment in order to grasp their visions for appropriate and improved prevention and treatment options. In particular, study participants highlighted how political determinants, notably the detrimental impact of the Israeli occupation, and social determinants, directly and indirectly influence behavioural determinants due to physical and bureaucratic barriers to accessing health facilities, economic hardship and chronic stress. These stressors, in turn, were perceived as having a negative effect on individual behavioural risk factors including smoking, unhealthy diet and an increasingly sedentary lifestyle. Proposed solutions included more focused interventions from the Ministry of Health as well as surveillance, primary prevention and health promotion, and management to positively effect behaviour change in order to address the growing burden of CVD in the region. CONCLUSIONS: The study has highlighted medical professionals' perceptions of how structural and individual behavioural determinants influence their own and individual patient's abilities to manage cardiovascular risk factors in a setting affected by chronic conflict. Consequently, we propose that medical and social intervention strategies generally used to address CVD risk, be strategically adapted in order to be useful and effective in contexts of armed conflict. Specifically, we call for a solid understanding of the socio-political context and existing health services as well as health providers' and patients' health beliefs and related behaviours when developing future health options aimed at addressing CVD in the region. Moreover, for health provision to be effective as well as sustainable, attention needs to be given above all towards a solution for political change.

[Regional differences in mortality and food and nutrient intake and their associations among secondary healthcare service areas in Hokkaido].

Objective　Hokkaido is a geographically vast area comprising a variety of natural environments and major industries. Therefore, we presume that there are large differences in lifestyles and lifestyle-related disease mortality in community people based on region. The aim of this study was to investigate the regional differences in mortality and food and nutrient intake, and their associations among secondary healthcare service areas in Hokkaido.Methods　This study's design was ecological. We collected mortality data using public health statistics from the year 2005 to 2009 of the Hokkaido prefecture. We calculated the average of the standardized mortality ratio (SMR) over those five years. Data on food and nutrient intake were obtained from the Hokkaido Health and Nutrition Survey in 2006 conducted in the Hokkaido prefecture. The association between mortality and nutritional status was examined using the Spearman rank correlation coefficient.Results　The mortality rates were higher in the southern and eastern areas of Hokkaido and in the lower internal area in the northern area of Hokkaido and the Tokachi area. There were regional differences of 400-500 kcal of energy, 20-30 g of protein, 4-5 g of salt, 60 g of green and yellow vegetables, and 100 g of other vegetables among 21 secondary healthcare service areas in Hokkaido.　In women alone, we observed a positive association between cancer mortality and fat intake from dairy products. By contrast, we observed an inverse, significant association between cancer mortality and rice intake, and cardiovascular mortality and soybean and soybean product intake, only in women.Conclusion　We present regional differences in mortality and food and nutrient intake among secondary healthcare areas in Hokkaido. We also reveal a significant association between mortality and food and nutrient intake only in women. Further research is needed to examine whether socioeconomic, environmental, or other lifestyle factors are associated with regional health gaps.