Archive for agosto 2012

Persistent cannabis users show neuropsychological decline from childhood to midlife

Recent reports show that fewer adolescents believe that regular cannabis use is harmful to health. Concomitantly, adolescents are initiating cannabis use at younger ages, and more adolescents are using cannabis on a daily basis. The purpose of the present study was to test the association between persistent cannabis use and neuropsychological decline and determine whether decline is concentrated among adolescent-onset cannabis users. Participants were members of the Dunedin Study, a prospective study of a birth cohort of 1,037 individuals followed from birth (1972/1973) to age 38 y. Cannabis use was ascertained in interviews at ages 18, 21, 26, 32, and 38 y. Neuropsychological testing was conducted at age 13 y, before initiation of cannabis use, and again at age 38 y, after a pattern of persistent cannabis use had developed. Persistent cannabis use was associated with neuropsychological decline broadly across domains of functioning, even after controlling for years of education. Informants also reported noticing more cognitive problems for persistent cannabis users. Impairment was concentrated among adolescent-onset cannabis users, with more persistent use associated with greater decline. Further, cessation of cannabis use did not fully restore neuropsychological functioning among adolescent-onset cannabis users. Findings are suggestive of a neurotoxic effect of cannabis on the adolescent brain and highlight the importance of prevention and policy efforts targeting adolescents.


Carlo Favaretti

Quando l’analisi economica ha un punto di vista societario e non si esaurisce in una valutazione d’impatto sul budget di un singolo ospedale!


Context  Visual impairment is a known risk factor for fractures. Little is known about the association of cataract surgery with fracture risk.

Objective  To determine the association of cataract surgery with subsequent fracture risk in US Medicare beneficiaries with a diagnosis of cataract.

Design, Setting, and Participants  Retrospective study of 1-year fracture incidence in a 5% random sample of Medicare Part B beneficiaries with cataract who received and did not receive cataract surgery from 2002 through 2009.

Main Outcome Measures  One-year incidence of hip fractures. Analyses were adjusted for age; sex; race/ethnicity; US region of residence; systemic comorbidities, including Charlson Comorbidity Index (CCI) score; ocular comorbidities; cataract severity; and presence of physically limiting conditions. Adjusted odds ratios (ORs) of hip fractures…

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XV^ CONFERENZA NAZIONALE HPH&HS – TRIESTE – Save the date: November 8, 2012 @carlofavaretti


La rete HPH & HS,un fondamento essenziale e non accessorio, utile per promuovere sistemi, reti e percorsi in un contesto sanitario in fase di riorganizzazione

Put patients to work during their wait time

by  | in PATIENT

I talk with lot of physicians about the need to improve the quality of communications between physicians and patients.   Regular followers of my work will know that I am an advocate for the adoption of patient-centered communication skills by the physician and provider community.

Physicians with whom I talk seldom disagree as to the need for better physician-patient communications.   They know that physician communication skills top the list of patient complaints about their physicians, i.e., my doctor doesn’t listen,” “my doctor ignores me,” and so on.   Rather, they simply dismiss the subject out of hand as being impractical due to a “lack of time” on the part of most physicians.

I can understand their perspective.   Primary care physicians in particular are faced with sicker, more demanding patients, increased payer and regulatory requirements, and are constantly pressured to see more patients.

Yet physician waiting rooms and exam rooms are full of engaged patients (otherwise they wouldn’t be there) who have nothing to do but read outdated magazine.

What would happen if physicians actually put patients to work during wait time?

Here’s what I mean.

What if physicians integrated patient “wait time” into the office visit by:

  • Talking to patients (via printed handouts, electronic media, patient portals, etc.) about their evolving new role (and that of the physician and other providers) under health reform.  Contrary to the popular press which touts the empowered patient, most of us still assume the traditional “sick role” during the office visit.  The sick role is characterized by patient passivity, limited information sharing, and minimal question-asking.
  • Teaching people while waiting how (using the same media as above) to become “better patients.”   I recall an article where physicians were asked 5 things they wished their patients knew.  At the top of the physicians’ “wish list” was a desire for patient’s to be better prepared and more focused during the visit.  The point being that more prepared patients would help the physician get to the correct diagnosis and treatment plan faster.

All of us, beginning in childhood, are socialized into playing the sick role when interacting with physicians.   Just as chronic disease patients needing to develop self care skills and confidence in their self care skills, patients need to be taught skills for (and develop confidence in) how to more effectively talk to and collaborate with their physicians.

Laying out a game plan (over a series of visits) for teaching new and established patients when and how to effectively contribute to the medical interview (exam).   Given an average wait time of 22 minutes per primary care visit, it is not reasonable to assume that patients can be taught the above in the course of 1 or 2 visits.  But patients with chronic conditions often visit their PCP 6-8 times a year.  This would afford plenty of time (2-3 hours a year) for physicians to teach (and practice) individual skills to patients (i.e., agenda setting and prioritization, question asking skills, self-care management skills, new medication considerations, etc.).   By reinforcing lessons learned by patients over the course of several visits, it is reasonable to expect that both patient and physician will become more proficient in the use of their time together.

How exactly will better physician-patient communication lead to more productive visits?

Research has consistently shown that patient-centered communications (versus traditional physician-directed communications) can result in more productive office visits as measured by 1)  the amount/quality of information shared by patients, 2) the number of questions asked by patients, and 3)  and the level of patient retention of information shared by physicians.

These same studies show that the adoption of patient-centered communications adds little if any more time to the length of office visits.  Once patients and physicians become proficient in the use of patient-centered communications methods,  physicians may well be able to do more during the visit but in less time.  Here are some of the techniques characteristic of patient-centered  communications associated with increased visit productivity:

  •  Concise visit agenda setting and prioritization wherein both physician and patient  agreed to what can be discussed within the time allowed.  This  also eliminates the “oh by the way” introduction of last-minute patient agenda items that can occur at the end of the visit.
  • More concise  sharing of relevant information by the patient
  • Greater physician-patient agreement as to the diagnosis and treatment
  • More collaborative decision-making
  • More information retention by patients
  • Greater patient adherence

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs atMind The Gap.

Finding the Facts of Healthcare Consumer Engagement and Shared Decision-Making @carlofavaretti

Max Hardy in

Just what is the general attitude of Australian health professionals to the practice of consumer and community engagement and shared decision-making?

That’s the very question we sought to answer via Twyfords’ just-completed national survey. Targeted at a wide cross-section of health professionals including executives, administrators, clinicians, academics and policy designers, our questionnaire was designed to ascertain:

• the perceived value of engagement in improving healthcare strategies
• the perceived value of shared decision-making in improving health outcomes
• the extent to which engagement and shared decision-making initiatives are resourced
• the types of benefits derived from engagement and shared decision-making
• the prevailing awareness around various methodologies

As far as we know, ours is one of the first attempts to examine and understand attitudes towards consumer engagement and shared decision-making within the Australian health sector.

Lack of benefit awareness

One message that rings out loud and clear is that awareness of recent research regarding the benefits of patient, consumer and community engagement is sorely lacking. Survey participants also indicated that such initiatives are under-resourced. Awareness around alternate and contemporary engagement approaches also seems to be limited. On the positive side, most survey participants believed their organisations benefited from whatever investment they made into working collaboratively with their consumers. Other respondents, meantime, believe their organisations don’t value consumer engagement at all, regarding any consumer involvement as merely tokenistic.Considering that research has demonstrated patients with a strong input into decision-making around their individual health plans are more likely to comply with those plans, this is a disappointing realisation. Indeed, for example, if patients feel they are being dictated to rather than listened to by healthcare professionals, it perhaps stands to reason they may be less likely to fully embrace a prescribed healthcare plan.

A readiness for change

 When it comes to grasping the full value and significance of shared decision-making and health consumer engagement, it’s fair to say we lag behind countries like the UK and North America. Encouragingly, the research has also shown there is a readiness to explore new ways of improving Australian healthcare delivery by tapping into the wisdom of health consumers and the wider public.