Who Benefits from Acute Psychiatric Home Treatment? A Systematic Review.

Home treatment (HT) treats patients in an acute crisis through an interdisciplinary team with daily appointments for a short treatment period. The effectiveness of HT has already been confirmed. However, only few studies addressed specific patient characteristics associated outcome of treatment. This study aimed to identify patient characteristics associated with successful outcomes of HT. A systematic literature search was conducted according to the PRISMA guidelines. A total of 13 studies were included in the systematic review. Being employed, having a regular income, having an anxiety disorder and family involvement were associated with a successful treatment outcome in HT. High symptom severity and former hospital admissions were associated with unsuccessful treatment outcome in HT in the selected studies. HT seems to be especially beneficial for patients with paid employment or regular income, patients with anxiety disorders, and patients with familial or other social support.

Study protocol of an observational study in acute psychiatric home treatment: How does home treatment work? Identification of common factors and predictors of treatment success.

BACKGROUND: Systematic reviews indicated that home treatment is an effective and cost-saving alternative to conventional acute psychiatric treatment options. Treatment success has often been defined as a reduction of hospital admissions. In the current study, symptoms and well-being are assessed regularly during treatment as an indicator for treatment success. Patients' characteristics such as diagnosis, age, substance use, and motivation for treatment were discussed as predictors for treatment success. A second focal point of the study lies in the examination of the therapeutic relationship in terms of the outcome, which has not yet been systematically investigated in home treatment. METHODS: This is an observational study with a prospective naturalistic design. Measurements are carried out at baseline, during and at the end of treatment as well as at the 3­month follow-up. Patients' characteristics as potential predictors for treatment success will be assessed at baseline. In addition, the perceived relationship between the patients and the team will be measured daily and weekly throughout the treatment. Treatment success is by the changes in symptoms and general well-being assessed weekly. We aim to include 82 participants assigned to home treatment. Variance analyses with repeated measurements will be conducted to evaluate treatment success. CONCLUSION: By examining potential patient- and relationship-related predictors of treatment success, insights into relevant determining variables of treatment success in this setting are expected. The results might help to better identify who benefits the most from home treatment.

Fairness and objectivity of a multiple scenario objective structured clinical examination.

Introduction: The aim of the Objective Structured Clinical Examination (OSCE) is a standardized and fair assessment of clinical skills. Observing second clinical year medical students during a summative OSCE assessing a General Practice clerkship, we noticed that information exchange with peers led to a progressively faster and overly focused management of simulations. Therefore, we established a Multiple Scenario-OSCE (MS-OSCE) where all students had to manage the same chief complaint at a station but it's underlying scenarios being randomly changed during students' rotation through their parcours. We wanted to ensure they fully explore differential diagnosis instead of managing their task influenced by shared information. We wanted to assess if a MS-OSCE violates the assumption of objectivity and fairness given that students are not tested with the same scenarios. Methods: We developed and piloted five OSCE stations (chest pain, abdominal pain, back pain, fatigue and acute cough) with two or three different underlying scenarios each. At each station these scenarios randomly changed from student to student. Performance was assessed with a checklist and global rating. The effect of scenarios and raters on students' grades was assessed calculating the intraclass correlation coefficient with a fixed effect two level linear model. Results: A total of 169 students and 23 raters participated in the MS-OSCE. The internal consistency over all stations was 0.65 by Cronbach's alpha. The difference of the mean grades between the scenarios of a given chief complaint ranged from 0.03 to 0.4 on a 1 to 5 grading scale. The effect of scenarios on the variance of the final grades at each station ranged from 4% to 9% and of raters from 20% to 50% when adjusted for students' skills. Conclusions: The effect of different scenarios on the grades was relevant but small compared to the effect of raters on grades. Improving rater training is more important to ensure objectivity and fairness of MS-OSCE than providing the same scenario to all students.

Diagnosis and management of non-dialysis chronic kidney disease in ambulatory care: a systematic review of clinical practice guidelines.

BACKGROUND: Chronic kidney disease (CKD) is age-dependent and has a high prevalence in the general population. Most patients are managed in ambulatory care. This systematic review provides an updated overview of quality and content of international clinical practice guidelines for diagnosis and management of non-dialysis CKD relevant to patients in ambulatory care. METHODS: We identified guidelines published from 2012-to March 2018 in guideline portals, databases and by manual search. Methodological quality was assessed with the Appraisal of Guidelines for Research and Evaluation II instrument. Recommendations were extracted and evaluated. RESULTS: Eight hundred fifty-two publications were identified, 9 of which were eligible guidelines. Methodological quality ranged from 34 to 77%, with domains "scope and purpose" and "clarity of presentation" attaining highest and "applicability" lowest scores. Guidelines were similar in recommendations on CKD definition, screening of patients with diabetes and hypertension, blood pressure targets and referral of patients with progressive or stage G4 CKD. Definition of high risk groups and recommended tests in newly diagnosed CKD varied. CONCLUSIONS: Guidelines quality ranged from moderate to high. Guidelines generally agreed on management of patients with high risk or advanced CKD, but varied in regarding the range of recommended measurements, the need for referrals to nephrology, monitoring intervals and comprehensiveness. More research is needed on efficient management of patients with low risk of CKD progression to end stage renal disease.

[Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study]. / Arzneimittelverordnung bei Patienten mit chronischer Niereninsuffizienz in der hausärztlichen Versorgung.

BACKGROUND: Many drugs require dose adjustment or are contraindicated in patients with chronic kidney disease (CKD) to avoid adverse events. The aims of this study were to assess if medication was appropriately dose adjusted in patients with CKD in primary care, to identify medications that were frequently prescribed inappropriately and to identify factors predicting mal-prescription. METHODS: We conducted a cross-sectional observational study in 34 general practioners' offices, assessing the medication of patients with CKD stage ≥ 3 according to the corresponding pharmaceutical product information. Additional information was extracted from recommendations of scientific societies and regulatory authorities. Contraindicated and overdosed medications were identified. Predictive factors for inadequate prescribing were analyzed with multiple logistic regression. RESULTS: 589 patients (Ø 78 years, 63 % female) with CKD stage ≥ 3 were included. A total of 5102 medications were extracted from the medication sheets (94,6 % regular, 5,4 % "as needed"). 4,2 % were judged as being inadequate according to pharmaceutical information (2,1 % contraindicated, 2,1 % overdosed). 173 patients (29 %) had ≥ 1 inadequate prescription. The proportion of inadequate prescriptions fell to 3,5 % after adjustment for the most recent recommendations of scientific societies and regulatory authorities. Most frequent inappropriate prescriptions were ACE-inhibitors, diuretics, oral antidiabetic drugs, methotrexate and potassium supplements. Most important predictors for inadequate prescriptions were CKD stage ≥ 3b and number of medications. CONCLUSION: A quarter of all patients had a least one inadequate prescription. The overall proportion of inadequately prescribed drugs was low. Adjustment for recommendations by scientific societies and regulatory authorities further reduced the number of inadequate prescriptions. Valid data on the clinical relevance of inadequate prescriptions is scarce and further research is required. Because of the time and effort needed to assess all medications, future quality improvement projects should focus on CKD stage ≥ 3b, patients with polypharmacy and crucial medication.

Self-efficacy as a predictor of outcome after residential treatment programs for alcohol dependence: simply ask the patient one question!

BACKGROUND: Self-efficacy has been identified as one of the most consistent variables that predict the outcome of alcohol treatment. However, many previous studies in this field failed to control for other important predictors (e.g., dependences severity, psychiatric symptoms, and treatment goal). Our study's first goal was to evaluate the predictive value of self-efficacy when most other relevant variables were statistically controlled. The second goal was to compare the predictive values of self-efficacy assessed with the Situational Confidence Questionnaire (SCQ), and general self-efficacy assessed with a single question. METHODS: Four hundred and fifteen patients with alcohol dependence from 12 residential alcohol use disorder (AUD) treatment programs were assessed at treatment admission, discharge, and the 1-year follow-up. A stepwise logistic regression for abstinence was calculated using all predictors. For those predictors that were significant, a Cox survival regression analysis was performed to predict the time to the first drink after discharge. RESULTS: Only abstinence as treatment goal, alcohol use during treatment, and general self-efficacy as measured by 1 question were revealed to be significant predictors in the stepwise regression, whereas all other variables, including self-efficacy as measured by the SCQ, were not significantly associated with abstinence at the 1-year follow-up. Cox survival regression analysis showed a significant difference in the time to first alcohol use between patients with maximum general self-efficacy and those with lower general self-efficacy, when the other 2 significant variables were controlled for. CONCLUSIONS: General self-efficacy, that is, the patients' own prognosis of his success in remaining abstinent, was a central variable in predicting residential alcohol dependence treatment outcome. Self-efficacy showed a more accurate prognosis of outcome when it was assessed with just 1 question, than when assessed with the SCQ. With this simplified assessment, knowledge of the prognostic value of self-efficacy could be made applicable for everyday practice.