Esra Meltem Koç

Shared Decision-Making in Pediatric Intensive Care Units: A Qualitative Study with Physicians, Nurses and Parents

ObjectivesTo understand how decisions are made in Intensive Care Unit (ICU) settings where critically-ill children require life-support decisions and what are the perceptions of health professionals and parents.MethodsIn this qualitative study, in-depth, semi-structured, face to face interviews with 8 doctors, 9 nurses and 6 parents of critically ill children were conducted. Interviews were digitally recorded and transcribed. The transcriptions were further analyzed following open coding and formation of themes.ResultsThe themes were discussed in two major titles: perceived roles and emotions during the decision-making process. All nurses and patients agreed that the decision maker should be the physician. Nurses understood patients’ emotions better and had a closer relation with the parents. Both doctors and nurses thought that parents could not have all responsibilities about treatment choices, because they do not have the required knowledge. Similarly parents were afraid to make a wrong decision, thus they wanted to leave this to the doctors.ConclusionsThe present study revealed that shared-decision making is not well understood by health care professionals in Turkey. Doctor is the major decision-making authority and this is also accepted and preferred by the patients and nurses.

Quality Assessment of Clinical Practice Guidelines Developed by Professional Societies in Turkey.

Background Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. There is a limited number of studies on guidelines in Turkey. The quality of Ministry of Health guidelines have formerly been assessed whereas there is no information on the other guidelines developed in the country. Aim This study aims to assess the quality of CPGs that are developed by professional societies that work for the health sector in Turkey, and compare the findings with international guidelines. Methodology Professional societies that work for the health sector were determined by using the data obtained from the Ministry of Internal Affairs. Inclusion and exclusion criteria were defined for selecting the CPGs. Guidelines containing recommendations about disease management to the doctors, accessible online, developed within the past 5 years, citing references for recommendations, about the diseases over 1% prevalence according to the “Statistical Yearbook of Turkey 2012” were included in the study. The quality of CPGs were assessed with the AGREE II instrument, which is an internationally recognized tool for this purpose. Four independent reviewers, who did not participate in the development of the selected guidelines and were trained in CPG appraisal, used the AGREE instrument for assessment of the selected guidelines. Findings 47 professional societies were defined which provided access to CPGs in their websites; 3 of them were only open to members so these could not be reached. 8 CPGs from 7 societies were selected from a total of 401 CPGs from 44 societies. The mean scores of the domains of the guidelines which were assessed by the AGREE II tool were; Scope and purpose: 64%, stakeholder involvement: 37.9%, rigour of development: 35.3%, clarity and presentation: 77.9%, applicability: 49.0% and editorial independence: 46.0%. Conclusion This is the first study in Turkey regarding quality appraisal of guidelines developed by the local professional societies. It adds to the limited amount of information in the literature that comes from Turkey as well as other developing countries.

HEALTH TECHNOLOGY ASSESSMENT IN TURKEY

OBJECTIVES The healthcare transformation program in Turkey has shown its success with improvements in important health indicators, increased access to healthcare services and expansion of coverage to all citizens. Turkey has been relatively able to bear the burdens associated with this due to rapid economic growth. The need for health technology assessment (HTA) was believed as a result of the expansion of coverage, pressure of new technologies, and increased expenditures. This study outlines the background and current formalization of HTA and shares the current use of HTA in decision making, while summarizing the transformation of the Turkish healthcare system for developing a high-quality, equal, and accessible care system. METHODS We reviewed and analyzed policy changes in the Turkish healthcare system, universal health coverage, healthcare expenditures, and pricing and reimbursement policies to identify the changes leading to HTA. We reviewed existing HTA functions in Turkey and outlined their activities. Finally, we outlined a set of major challenges for HTA in Turkey over the next decade. RESULTS HTA was formalized in Turkey in 2012-2013 with three national HTA structures and one hospital-based HTA unit. These functions currently run independent from each other. There are three major challenges in this country for HTA in the next decade: clarification of the assessment scope and methods, building a strong supporting system for HTA, and defining the role of HTA in the future vision of Turkish healthcare policy. CONCLUSION HTA, despite challenges, has a good opportunity to develop further with clear action plans and strong political will.

Evaluation of dietary habits during pregnancy

Objective: Pregnancy is a special period of increased nutritional needs during which conscious nutritional support is required. Insufficient and imbalanced nutrition in this period of life causes serious conditions that affect both child and mother. This study aimed to evaluate the relationship between pregnancy and nutrition/nutritional habits during pregnancy. Materials and Methods: In this descriptive study, a questionnaire was conducted on a voluntary basis to pregnant women who were admitted to the Pregnancy Outpatient Clinic of Obstetrics and Gynecology Department at Ankara Numune Training and Research Hospital. Questions about general information, pregnancy-related information, thoughts and knowledge about breastfeeding, nutritional habits, and meal frequency were asked to pregnant women. Three hundred fourteen questionnaires were assessed in the study. SPSS for Windows Version 16.0 and MS-Excel 2007 were used for statistical evaluations. P<0.05 was accepted as statistical significance. Results: There was a statistically significant relationship between pre-pregnancy body mass index (BMI) and number of pregnancies; level of education and income levels; number of children and history of caesarian section as an additional problem within previous pregnancies. The change of nutritional habits during pregnancy was examined; we found that consumption of fruits (51%) and vegetables (40.8%) increased the most, while intake of tea (26.1%) and redmeat (21%) mainly decreased during pregnancy. It was found that during pregnancy 20.4% of pregnant women had never consumed fish, 13.1% abstained from red meat, and 12.4% excluded white meat from their diet. Conclusions: We believe that this study will help to raise awareness about adequate and balanced nutrition during pregnancy and to define special nutritional recommendations.

A taboo in healthcare; life support decisions at the terminal stage

Saglik sisteminin daha etkin islemesi icin saglik hizmetinin hedef kitlesi olan halkin da sisteme aktif olarak dâhil olmasi gerekmektedir. Tedavi kararlarina katilimin orneklerinden birisi olan gelismis saglik direktifleri cok ciddi bir hastalik durumunda kisinin kendisine verilecek olan saglik hizmeti ile ilgili taleplerini iceren veya hastanin kendi kararlarini alamayacak duruma geldiginde, yerine karar alacak kisiyi tayin ettigi yazili belgelerdir. Yasam vasiyeti, yasal saglik yetkilisi, resusitasyon etmeme direktifi, yasam desteginin kisitlanmasi, yasam desteginin sonlandirilmasi bu direktifler icerisinde yer alir. Gelismis saglik direktifleri, basta Amerika Birlesik Devletleri (ABD) ve Avrupa’nin bazi ulkelerinde uygulanmaktadir. Gelismis saglik direktiflerinin ulkelere gore hukuki durumlari farklilik gostermektedir. Ulkemizde ise gelismis saglik direktifi kullanimina ve yazimina iliskin herhangi bir veri yoktur. Son donem hasta bakiminin hem bireysel hem de toplumsal anlamda getirdigi maddi ve manevi yukler dikkatli analiz edilip, ulkemizde de artik kisilerin son donemleri hakkinda onceden karar verebilmesi ile bu kararlarin uygulanabilmesi konusu tartisilmaya baslanmalidir.

The ideas about advanced life support and affecting factors at the end-stage of life in a hospital in Turkey

Background The participation of the people in health decisions may be structured in various levels. One of these is participation in decisions for the treatment. “Advanced directives” is one of the examples for the participation in decisions for the treatment. Aim We wanted to determine the decisions on advanced life support at the end-stage of life in case of a life-threatening illness for the people themselves and their first degree relatives and the factors effecting these decisions. Design and setting The cross-sectional study was conducted with volunteers among patients and patient relatives who applied to all polyclinics of the Ankara Numune Training and Research Hospital except the emergency, oncology and psychiatry polyclinics between 15.12.2012 and 15.03.2013. Method A questionnaire, the Hospital Anxiety Depression (HAD) scale, and Templer’s Death Anxiety Scale (TDA) were applied to all individuals. SPSS for Win. Ver. 17.0 and MS-Excel 2010 Starter software bundles were used for all statistical analysis and calculations. Results The participants want both themselves and their first degree relatives included in end-stage decision-making process. Therefore, the patients and their families should be informed adequately during decision making process and quality communication must be provided. Conclusion Participants who have given their end-stage decisions previously want to be treated according to these decisions. This desire can just be possible by advanced directives.When moral and material loads of end-stage process are taken into consideration, countries, in which advanced directives are practiced, should be examined well and participants’ desire should be evaluated in terms of practicability.

Hastane çalışanlarının sigara içme düzeylerinin belirlenmesi ve dumansız hava sahası uygulamasının değerlendirilmesi

Objective: The aim of this study is to define the health knowledge, cigarette smoking behaviors, attempts and successes to quit smoking and obstacles indicated by the ones who still smoke among a Training and Research Hospital staff four years after the application of the law “Smoke Free Air Zone”. Methods: A questionnaire developed by the researchers is used for this cross sectional research. It questions the sociodemographic features and thoughts and attitudes about the “Smoke Free Air Zone” and “Smoke Free Hospital” applications. Fagerstrom Nicotine Dependence Test is also applied to the smoking attendants to define the level of dependence. Results: It was found that 29.6% of the participants still smoke. Among the still smoking ones; 29.4% did not ever attempt to quit, 28.2% attempted before starting work in the hospital, 20% attempted after starting work in the hospital and 22.4% attempted on both periods. Regarding the questions about application of “Smoke Free Hospital” it was found that 70.7% of the hospital staff support the application, 53.3% think that violators should be punished with a penalty, 48.1% think that it should be punished by the administration, 30.1% think that passive smoking is an intrusion to the personal rights and 59.1% think that quitters increased with this application. Conclusion: Reducing the smoking rates among healthcare staff is extremely important in the struggle against smoking. Establishment of applications with institutional education programs and easing access to the related services may be helpful for healthcare personnel quit smoking. J Clin Exp Invest 2015; 6 (1): 33-39