Kristin Hendrickx

The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review

BackgroundTherapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition.MethodsA systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method.ResultsThe final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), “who” (physician, patient or system), “how and why” (mechanisms and reasons), and “appropriateness”. Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation.ConclusionsOur data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.

The critical appraisal of focus group research articles

Background: Focus group discussions are becoming an increasingly popular methodology in primary healthcare research. They can be used to understand peoples beliefs, opinions and attitudes about the topic of interest. With the increasing emphasis on critical appraisal of scientific research, it is obvious that reporting qualitative research has to be transparent. Not only should the methodology itself be easy to understand and evaluate, but also the question whether focus group methodology is the most appropriate way to serve the research question should be answered. Focus group discussions are relatively new to biomedical journals, often resulting in misunderstanding and frustration for authors, reviewers and editors. Objectives: To develop a reliable and valid checklist for the critical appraisal of focus group research articles for the information of referees and editors of medical journals, commissioners of research, but most of all to help authors to report transparently. Methods: A review of the literature in different databases from 1990 to 2000 using the keywords “qualitative research”, “focus groups”, “methodology” and “standards” resulted in a checklist being issued. This checklist was submitted to an expert panel, its feasibility was addressed and the inter-rater agreement was assessed by members of the European General Practice Research Workshop. Results: A critical appraisal checklist for focus group research articles. Conclusions: The checklist does not replace training in the research method but it can act as a tool for authors, reviewers, editors and commissioners of research.

Learning intimate examinations with simulated patients: the evaluation of medical students' performance

Background: For fifth-year undergraduates of the medical school, a project with simulated patients (Intimate Examination Associates, IEA) was implemented in 2002 at the University of Antwerp. In this project, students from the new curriculum (NC) learned uro-genital, rectal, gynaecological and breast examination in healthy, trained volunteers and received feedback focused on personal attitude, technical and communication skills. Former curriculum (FC) students however trained these skills only during internship in the sixth year after a single training on manikins. Aims: This study assessed the effect of learning intimate examinations with IEAs by comparing students from FC and NC on four different outcome parameters. Methods: Three groups were compared: FC after internships without IEA training, NC after internships with IEA training and fifth year NC immediately after the IEA training. Four assessment instruments: an OSCE using checklists and global rating scales to assess the technical skills, a score list on students attitudes and performance filled in by the IEAs, a student questionnaire on self-assessed competence and a questionnaire on the frequency of performing intimate skills during internships. Results: Both NC groups scored globally better in the OSCE (significance for male examination). Sub-scores for ‘completeness’ and ‘systematic’ approach was significantly higher in both NC groups for male and female examinations. NC students reported better self-assessed competence and performance concerning gynaecological and urological clinical and communication skills during internship. The best results were obtained after IEA training and internship was done for the four outcomes. IEAs are influenced by the ‘experienced’ students after internship: FC and NC after internship both scored better than the fifth year NC who only received the IEA training so far. Conclusion: Learning intimate examinations with IEAs has a positive effect on the performance of medical students. This beneficial effect is on its turn reinforced during internships.

Impact of family medicine clerkships in undergraduate medical education: a systematic review.

Objective Synthesise evidence about the impact of family medicine/general practice (FM) clerkships on undergraduate medical students, teaching general/family practitioners (FPs) and/or their patients. Data sources Medline, ERIC, PsycINFO, EMBASE and Web of Knowledge searched from 21 November to 17 December 2013. Primary, empirical, quantitative or qualitative studies, since 1990, with abstracts included. No country restrictions. Full text languages: English, French, Spanish, German, Dutch or Italian. Review methods Independent selection and data extraction by two authors using predefined data extraction fields, including Kirkpatrick’s levels for educational intervention outcomes, study quality indicators and Best Evidence Medical Education (BEME) strength of findings’ grades. Descriptive narrative synthesis applied. Results Sixty-four included articles: impact on students (48), teaching FPs (12) and patients (8). Sample sizes: 16-1095 students, 3-146 FPs and 94-2550 patients. Twenty-six studies evaluated at Kirkpatrick level 1, 26 at level 2 and 6 at level 3. Only one study achieved BEME’s grade 5. The majority was assessed as grade 4 (27) and 3 (33). Students reported satisfaction with content and process of teaching as well as learning in FM clerkships. They enhanced previous learning, and provided unique learning on dealing with common acute and chronic conditions, health maintenance, disease prevention, communication and problem-solving skills. Students’ attitudes towards FM were improved, but new or enhanced interest in FM careers did not persist without change after graduation. Teaching FPs reported increased job satisfaction and stimulation for professional development, but also increased workload and less productivity, depending on the setting. Overall, student’s presence and participation did not have a negative impact on patients. Conclusions Research quality on the impact of FM clerkships is still limited, yet across different settings and countries, positive impact is reported on students, FPs and patients. Future studies should involve different stakeholders, medical schools and countries, and use standardised and validated evaluation tools.

Correlates of safe sex behaviour among low-educated adolescents of different ethnic origin in Antwerp, Belgium

Background Several reports suggest that low educated adolescents of ethnic minority origin are at a higher risk of acquiring a sexually transmitted infection (STI) than autochthonous teens. On the other hand, focus group research with young Moroccan boys revealed a positive attitude towards condom use; they claim to use a condom even more frequently than their Belgian peers. The aim of this study is to document the behavioural, educational and social correlates that influence the use of condoms among low educated adolescents of different origin. Method Data from 378 questionnaires completed by 253 native Belgian and 125 ethnic minority adolescents, mostly Moslems, were analysed with the statistic software: SPSS. Results were interpreted according to the behavioural science ASE model (Attitude, Social influences, self-Efficacy). Results Native boys discuss sexual items more frequently with their parents and sexual partner, while boys in the other group address their questions more frequently to teachers, pharmacists and doctors. In both groups the most important correlate of safe sex intention and behaviour is the self-efficacy variable ‘both partners taking the initiative with regard to condom use’. This correlate refers to communication skills. Parental support and quality of general communication about sexuality with the parents are very important for both groups. A positive attitude of peers influences the intention of condom use in both groups. Conclusion There is no significant difference in sexual activity and safe sex behaviour between native boys and young males of ethnic minority. Self efficacy (correct condom use and taking the initiative) is the most prominent predictor of safe sex behaviour in both groups.

Unintentional failure to assess for experience in senior undergraduate OSCE scoring.

Context  One goal of undergraduate assessment is to test students’ (future) performance. In the area of skills testing, the objective structured clinical examination (OSCE) has been of great value as a tool with which to test a number of skills in a limited time, with bias reduction and improved reliability. But can OSCEs measure undergraduate internship expertise in basic clinical skills?

General practitioners’ justifications for therapeutic inertia in cardiovascular prevention: an empirically grounded typology

Objective To construct a typology of general practitioners’ (GPs) responses regarding their justification of therapeutic inertia in cardiovascular primary prevention for high-risk patients with hypertension. Design Empirically grounded construction of typology. Types were defined by attributes derived from the qualitative analysis of GPs’ reported reasons for inaction. Participants 256 GPs randomised in the intervention group of a cluster randomised controlled trial. Setting GPs members of 23 French Regional Colleges of Teachers in General Practice, included in the EffectS of a multifaceted intervention on CArdiovascular risk factors in high-risk hyPErtensive patients (ESCAPE) trial. Data collection and analysis The database consisted of 2638 written responses given by the GPs to an open-ended question asking for the reasons why drug treatment was not changed as suggested by the national guidelines. All answers were coded using constant comparison analysis. A matrix analysis of codes per GP allowed the construction of a response typology, where types were defined by codes as attributes. Initial coding and definition of types were performed independently by two teams. Results Initial coding resulted in a list of 69 codes in the final codebook, representing 4764 coded references in the question responses. A typology including seven types was constructed. 100 GPs were allocated to one and only one of these types, while 25 GPs did not provide enough data to allow classification. Types (numbers of GPs allocated) were: ‘optimists’ (28), ‘negotiators’ (20), ‘checkers’ (15), ‘contextualisers’ (13), ‘cautious’ (11), ‘rounders’ (8) and ‘scientists’ (5). For the 36 GPs that provided 50 or more coded references, analysis of the code evolution over time and across patients showed a consistent belonging to the initial type for any given GP. Conclusion This typology could provide GPs with some insight into their general ways of considering changes in the treatment/management of cardiovascular risk factors and guide design of specific physician-centred interventions to reduce inappropriate inaction. Trial registration number NCT00348855.

Are recent graduates enough prepared to perform obstetric skills in their rural and compulsory year? A study from Ecuador

Objectives The aim of this study was to assess the possible mismatch of obstetrical skills between the training offered in Ecuadorian medical schools and the tasks required for compulsory rural service. Setting Primary care, rural health centres in Southern Ecuador. Participants A total of 92 recent graduated medical doctors during their compulsory rural year. Primary and secondary outcomes measures A web-based survey was developed with 21 obstetrical skills. The questionnaire was sent to all rural doctors who work in Loja province, Southern Ecuador, at the Ministry of Health (n=92). We measured two categories ‘importance of skills in rural practice’ with a five-point Likert-type scale (1= strongly disagree; 5= strongly agree); and ‘clerkship experience’ using a nominal scale divided in five levels: level 1 (not seen, not performed) to level 5 (performed 10 times or more). Spearmans rank correlation coefficient (r) was used to observe associations. Results A negative correlation was found in the skills: ‘episiotomy and repair’, ‘umbilical vein catheterisation’, ‘speculum examination’, ‘evaluation of cervical dilation during active labour’, ‘neonatal resuscitation’ and ‘vacuum-assisted vaginal delivery’. For instance ‘Episiotomy and repair’ is important (strongly agree and agree) to 100% of respondents, but in practice, only 38.9% of rural doctors performed the task three times and 8.3% only once during the internship, similar pattern is seen in the others. Conclusions In this study we have noted the gap between the medical needs of populations in rural areas and training provided during the clerkship experiences of physicians during their rural service year. It is imperative to ensure that rural doctors are appropriately trained and skilled in the performance of routine obstetrical duties. This will help to decrease perinatal morbidity and mortality in rural Ecuador.

Defining a framework for medical teachers' competencies to teach ethnic and cultural diversity: Results of a European Delphi study

Abstract Background: Medical students need to be trained in delivering diversity-responsive health care but unknown is what competencies teachers need. The aim of this study was to devise a framework of competencies for diversity teaching. Methods: An open-ended questionnaire about essential diversity teaching competencies was sent to a panel. This resulted in a list of 74 teaching competencies, which was sent in a second round to the panel for rating. The final framework of competencies was approved by the panel. Results: Thirty-four experts participated. The final framework consisted of 10 competencies that were seen as essential for all medical teachers: (1) ability to critically reflect on own values and beliefs; (2) ability to communicate about individuals in a nondiscriminatory, nonstereotyping way; (3) empathy for patients regardless of ethnicity, race or nationality; (4) awareness of intersectionality; (5) awareness of own ethnic and cultural background; (6) knowledge of ethnic and social determinants of physical and mental health of migrants; (7) ability to reflect with students on the social or cultural context of the patient relevant to the medical encounter; (8) awareness that teachers are role models in the way they talk about patients from different ethnic, cultural and social backgrounds; (9) empathy for students of diverse ethnic, cultural and social background; (10) ability to engage, motivate and let all students participate. Conclusions: This framework of teaching competencies can be used in faculty development programs to adequately train all medical teachers.

Consensus study to define appropriate inaction and inappropriate inertia in the management of patients with hypertension in primary care

Objectives To elaborate and validate operational definitions for appropriate inaction and for inappropriate inertia in the management of patients with hypertension in primary care. Design A two-step approach was used to reach a definition consensus. First, nominal groups provided practice-based information on the two concepts. Second, a Delphi procedure was used to modify and validate the two definitions created from the nominal groups results. Participants 14 French practicing general practitioners participated in each of the two nominal groups, held in two different areas in France. For the Delphi procedure, 30 academics, international experts in the field, were contacted; 20 agreed to participate and 19 completed the procedure. Results Inappropriate inertia was defined as: to not initiate or intensify an antihypertensive treatment for a patient who is not at the blood pressure goals defined for this patient in the guidelines when all following conditions are fulfilled: (1) elevated blood pressure has been confirmed by self-measurement or ambulatory blood pressure monitoring, (2) there is no legitimate doubt on the reliability of the measurements, (3) there is no observance issue regarding pharmacological treatment, (4) there is no specific iatrogenic risk (which alters the risk-benefit balance of treatment for this patient), in particular orthostatic hypotension in the elderly, (5) there is no other medical priority more important and more urgent, and (6) access to treatment is not difficult. Appropriate inaction was defined as the exact mirror, that is, when at least one of the above conditions is not met. Conclusion Definitions of appropriate inaction and inappropriate inertia in the management of patients with hypertension have been established from empirical practice-based data and validated by an international panel of academics as useful for practice and research.