Fluent Essays

Complete an article analysis for the Article Analysis 2. Article 1- Smoking CessationArticle 2- Outcomes of a physiotherapy-led pelvic health clinicAPA is no required however must have solid academic writing and statistical material. Example provided. hlt_362v_article_analysis_2.docx smoking_cessation.pdf physiotherapy_led_pelvic_health.pdf hlt_362v_rs3_articleanalysisexample_2.docx Unformatted Attachment Preview Article Analysis 2 Article Citation and Permalink (APA format) Article 1 Article 2 Girvalaki, C., Papadakis, S., Vardavas, C., Petridou, E., Pipe, A., Lionis, C., … Theodoros, V. (2017). Smoking cessation delivery by general practitioners in Crete, Greece. European Journal of Public Health, 28(3), 542–547. https://doi.org/10.1093/eurpub/ckx 201 Nucifora, J., Howard, Z., Jackman, A., Bongers, M., Corcoran, K., Weir, K. A., & Briffa, K. (2018). Outcomes of a physiotherapy-led pelvic health clinic. Australian & New Zealand Continence Journal, 24(2), 43–50. 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The European Journal of Public Health, Vol. 28, No. 3, 542–547 ß The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckx201 Advance Access published on 13 November 2017 ......................................................................................................... Smoking cessation delivery by general practitioners in Crete, Greece Charis Girvalaki1, Sophia Papadakis1,2,3, Constantine Vardavas1, Eleni Petridou4, Andrew Pipe2,3, Christos Lionis1, on behalf of the Practice Based Research Network in Primary Care in Crete 1 2 3 4 Department of Medicine, Clinic of Social and Family Medicine, University of Crete, Heraklion, Crete, Greece Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada Division of Cardiology, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece  The members of the Practice Based Research Network in Primary Care in Crete are listed in the Acknowledgements. Correspondence: Charis Girvalaki, Department of Medicine, Clinic of Social and Family Medicine, University of Crete, PO Box 70013, Heraklion, Crete, Greece, Tel: +30 2810 394596, Fax: +30 2810 394606, e-mail: charis@tobcontrol.eu Background: Tobacco dependence treatment in clinical settings is of prime public health importance, especially in Greece, a country experiencing one of the highest rates of tobacco use in Europe. Methods: Our study aimed to examine the characteristics of tobacco users and document rates of tobacco treatment delivery in general practice settings in Crete, Greece. A cross-sectional sample of patients (n = 2, 261) was screened for current tobacco use in 25 general practices in Crete, Greece in 2015/16. Current tobacco users completed a survey following their clinic appointment that collected information on patient characteristics and rates at which the primary care physician delivered tobacco treatment using the evidence-based 4 A’s (Ask, Advise, Assist, Arrange) model during their medical appointment and over the previous 12-month period. Multi-level modeling was used to analyze data and examine predictors of 4 A’s delivery. Results: Tobacco use prevalence was 38\% among all patients screened. A total of 840 tobacco users completed the study survey [mean age 48.0 (SD 14.5) years, 57.6\% male]. Approximately, half of the tobacco users reported their general practitioner ‘asked’ about their tobacco use and ‘advised’ them to quit smoking. Receiving ‘assistance’ with quitting (15.7\%) and ‘arranging’ follow-up support (<3\%) was infrequent. Patient education, presence of smoking-related illness, a positive screen for anxiety or depression and the type of medical appointment were associated with 4 A’s delivery. Conclusion: Given the fundamental importance of addressing tobacco treatment, increasing the rates of 4 A’s treatment in primary care settings in Greece is an important target for improving patient care. ......................................................................................................... Introduction obacco use is the leading cause of premature death and disability 1,2 Each year, more than 700 000 Europeans die from tobacco-related illness.2 The World Health Organization’s (WHO) European region has one of the highest proportions of death attributable to tobacco, with an estimated 16\% of all deaths among adults over 30 years of age due to tobacco use.1 Despite the decline in the prevalence of tobacco use, more than 125 million Europeans (26\% of the population) continue to smoke, representing the highest rate of tobacco use among all the WHO regions.3 Moreover, tobacco use imposes a huge economic burden on the European health care systems, with the direct health care costs alone estimated to be 100 billion Euros.4,5 There is overwhelming evidence attesting to the health and economic benefits of smoking cessation.6 Quitting smoking reduces the excess risk of smoking-related coronary heart disease, for example, by approximately 50\% within 1 year, and to normal levels within 5 years.7 Smoking cessation is highly cost-effective with the cost per life-year saved estimated to be between ?1500 and ?3000.8,9 Tobacco use is also a priority among young European due to the fact that 94\% of smokers start smoking before the age of 25 years and quitting smoking as early in life substantially reduces future disease risk.10 General practices have been identified as important settings for the delivery of smoking cessation treatment.1,4,11,12 The WHO1 and the European Network For Smoking and Tobacco Prevention13 Tand the largest threat to public health in Europe. Downloaded from https://academic.oup.com/eurpub/article-abstract/28/3/542/4621433 by Adam Ellsworth, Adam Ellsworth on 25 May 2018 have called for tobacco dependence to be a clinical priority of all health professionals.1,13 The 5A’s of smoking cessation are an internationally recognized evidence-based schema to guide interventions with tobacco users in all clinical settings including primary care.13,14 The 5 As include: ‘ask’ patients about smoking status; provide brief quit smoking ‘advice’; ‘assess’ readiness to quit smoking; ‘assist’ patients with making a quit attempt using behavioral techniques and pharmacotherapies; and, ‘arrange’ follow-up support throughout the quitting process. Internationally, and in Europe, a practice gap in rates of 5 As delivery in clinical settings has been documented.15–17 Greece has one of the highest rates of tobacco use among members of the European Union, estimated at 38\% of the adult population.3 Little is known about the characteristics of tobacco users and current rates of tobacco treatment delivery in primary care settings in Greece. As a consequence, this study sought to examine the characteristics of tobacco users visiting general practitioners (GPs) in Crete, Greece and to document the rates of tobacco treatment delivery. We also examined patient-, GP- and clinic-level predictors of tobacco treatment delivery. Methods Design and setting Here, we report the cross sectional baseline data collected as part of the Global Bridges TiTAN Crete project. The purpose of the TiTAN Smoking cessation delivery by general practitioners in Crete Crete project (http://titan.uoc.gr/index_en.html) is to create a network of GPs trained in evidence-based smoking cessation treatments. Data collection took place in Crete, Greece between May 2015 and June 2016. GPs were surveyed and a cross-sectional sample of their patients was screened for current tobacco use. All current tobacco users were asked to complete a survey following their clinic appointment. The survey documented the characteristics of tobacco users and assessed rates at which their GPs delivered tobacco treatment during the patient’s same day medical appointment (index visit) and during the previous 12-month period. The study received ethics approval from the University Hospital of Heraklion Ethics Board (ref# 18078). Procedures During recruitment, all GPs located in the regions of Heraklion and Rethymnon in Crete, Greece were invited to participate in the study by email. To be eligible for the study GPs need to be: currently working in Primary Health Care practice in the geographic recruitment area. Twenty-five of twenty-six eligible GPs agreed to participate (response rate 96.2\%). A follow-up telephone call was made by a member of the project team to confirm interest in participation. Informed consent was obtained from all participating GPs. GPs completed a questionnaire to document demographic characteristics including: age, gender, number of years practicing medicine, previous cessation training and personal smoking status. A standardized description of clinic characteristics was assembled; it included details of practice size, geography, payment methods and use of an electronic medical record. Within all participating GP’s offices, consecutive patients (n = 2261) were screened for eligibility using a brief written survey administered in the waiting room of the practice upon arrival for their appointment. Eligibility criteria included: being 18-years of age or older; a current tobacco user (1 cigarette per day on most days of the week); attending clinic for a non-urgent medical visit; and, ability to understand Greek. Eligible patients who agreed to participate in the study provided informed consent (n = 840, response rate 97.7\%) and were asked to complete a brief survey following their medical appointment. The patient survey collected demographic variables (age, sex, ethnicity, years of formal education, occupation, income and postal code), a brief medical history and smoking related variables. The presence of any smoking-related illness was documented including heart disease, stroke, chronic obstructive pulmonary disease and cancer. A validated Greek version of the four-item Patient Health Questionnaire (PHQ), a tool used by health care professionals for diagnosing mental health disorders was administered.18,19 The two-item Heaviness of Smoking Index (HSI) was used to assess the degree of nicotine dependence.20,21 The HSI score ranges from 0 to 6 with higher HSI scores reflecting greater nicotine dependence. Smoking history was assessed by documenting the number of years a participant had been smoking. The number of previous quit attempts (lasting 24-h or longer) in the past year was also documented. Consistent with previous research, performance in the delivery of each of the 4 A’s (ask, advise, assist, arrange) was assessed using an exit survey.22 The survey instructed participants to respond either ‘yes’, ‘no’ or ‘don’t know’ when asked whether their GP asked them about their smoking status (ask); advised them to quit smoking (advise); provided assistance with quitting (assist); or arranged follow-up support (arrange). For ‘assist,’ we further examined the type of assistance provided including whether or not the GP: prescribed pharmacotherapy, provided self-help materials; or set a quit date. Participants were asked to respond regarding their receipt of those interventions during that day’s clinic appointment (i.e. the index appointment) as well as at any time in the previous 12months. We chose not to measure rates at which providers assessed readiness to quit smoking in the present study. A research Downloaded from https://academic.oup.com/eurpub/article-abstract/28/3/542/4621433 by Adam Ellsworth, Adam Ellsworth on 25 May 2018 543 assistant coordinated all screening and data collection activities in clinic waiting rooms. For patients unable to read/write the research assistant completed the survey by interview. The Consolidated Standards of Reporting Trials flow diagram for the study is presented as Supplementary figure S1. Statistical analysis Descriptive statistics assessed GP characteristics, patient characteristics and rates of delivery of the 4 A’s. Given the clustered nature of data collection, each participating patient was linked to their GP. Multi-level modeling was used to account for provider-level clustering.23 An intra-class correlation coefficient (ICC) was calculated to describe the variation among GPs in rates of 4 A’s delivery and significance was assessed. The ICC ranges from 0 to 1 with higher scores indicating larger variation among providers in rates of 4 A’s delivery.23 In order to understand the patient-level, GP-level, and clinic-level factors associated with each outcome, separate multi-level logistic regression analyzes were completed. A block approach was used to examine the factors from each of the three levels that were associated with each outcome in a separate logistic regression model. Variables from each level that were significantly associated with each outcome at P < 0.1 were included in a final model; only variables that were significantly associated with each outcome at P < 0.05 were retained in the final model. Results were reported as adjusted odds ratios (AOR) and 95\% confidence intervals (CI). SAS 9.4 was used to conduct multi-level modeling. Results The majority of GPs were under the age of 50-years (95.8\%) and practicing in rural settings. Twenty-five percent of GPs reported current personal tobacco use while less than thirty-five percent of them reported they had the necessary skills to support their patients with quitting. Supplementary table S1 presents data on characteristics of providers. The prevalence of tobacco use among the patients was estimated at 38\%, their mean age was 48.0 (SD 14.5) years, and 57.6\% were male (table 1). The majority of tobacco users had smoked for more than 20-years (67.4\%) and reported high rates of daily tobacco consumption (mean 21.1 SD  11.9). Overall, 65.4\% of participants reported smoking within the first 30-min of waking while 58\% of them were thinking of quitting in the next 6-months. Less than 40\% of those surveyed reported making a quit attempt in the previous year. The majority of respondents reported low self-efficacy with quitting while 71.0\% of tobacco users rated their GP’s advice to quit as important or very important. Rates of 4 A’s delivery At the index visit 50.3\% of patient reported receiving advice to quit smoking from their GP however, only 11.1\% of patients reported receiving assistance with smoking cessation. A similar pattern was documented for the previous 12-months. Discussing and prescribing quit smoking medications and the provision of self-help material occurred infrequently at both the index visit and during the previous 12-months (table 2). ICCs indicate substantial interprovider variability for ‘ask’, ‘advice’ and ‘assist’ (table 3). ICCs for the specific forms of assistance (i.e. self-materials, prescribe pharmacotherapy) and arrange were non-significant. Figure 1 provides a visual depiction of rates of 4 A’s delivery by GP. Predictors of 4 A’s delivery The final model of the multi-level analysis examining predictors of 4 A’s delivery is presented as table 3. Male GPs were significantly more likely to ‘advise’ patients about the health hazards of smoking and the value of cessation (AOR 2.88; 95\% CI 1.06, 7.86; P < 0.05). 544 European Journal of Public Health Table 1 Socio-demographic and tobacco-related characteristics of primary care patients sampled (n = 840) in Crete, Greece Table 2 Rates of 4 A’s tobacco treatment among GPs at index visit and previous 12-months, in Crete, Greece Parameter Response Value Parameter \% Index \% Previous ICC visitn = 752 12-monthsn = 805 Age Sex Number of cigarettes (daily) Education (years) Mean years (SD) \% Male Mean years (SD) 0–6 7–9 10–12 12+ Greek Yes Score of  3 Score of  3 <5 6–15 16–25 26–40 >40 After 60 mins 31–60 mins 6–30 mins Within 5 mins High Moderate Low 0–2 3–9 10–19 20+ Next 30 days Next 6-months Not ready to quit Low (7/10) High (>7/10) 0 1–2 3+ Yes None Some Most All Low (7/10) High (>7/10) Very important Important Somewhat important Not at all important 48.0 (14.5) 57.6\% 21.1 (11.9) 21.7\% 20.1\% 30.1\% 27.9\% 97.9\% 18.8\% 6.9\% 15.5\% 4.8\% 32.3\% 39.4\% 19.9\% 3.7\% 20.4\% 14.3\% 35.6\% 29.8\% 20.6\% 56.1\% 23.3\% 1.2\% 7.9\% 23.6\% 67.4\% 24.2\% 34.2\% 41.6\% 85.5\% 14.5\% 61.4\% 32.5\% 6.1\% 58.1\% 4.2\% 38.9\% 52.6\% 4.3\% 37.5\% 62.5\% 21.4\% 49.6\% 18.6\% 10.4\% Ask Advise Quit smoking Health hazards Assist General assistance Set quit date Provide self-help material Discuss medications Prescribe medication Arrange 55.7 63.2 0.494 0.006 50.3 32.1 58.3 46.4 0.422 0.006 0.292 0.007 11.1 4.4 2.7 5.3 0.9 2.8 15.7 3.5 5.7 7.8 1.5 2.5 0.459 0.687 0.431 0.884 0.883 0.688 Nationality Smoking-related illnessa Depressionb Anxietyc Cigarettes/day Time to first cigarette HSI Years of smoking Readiness to quitd Self-efficacy with quittinge Number of quit attempts in past year Presence of Other smokers in the home Family/friends who smoke Perceived importance of quittingf Importance of doctor’s advice to quit a: Self- Reported heart disease, stroke, heart failure/cancer/chronic obstructive pulmonary disease (COPD)? (1 = yes, 0 = no). b: PHQ-4 for depression. c: PHQ-4 for anxiety. d: Which of the following best describes your feelings about smoking right now? (Responses: 1 = ready to quit in next 30 days, 0= ready to quit in next 6-months or not ready to quit). e: On a scale of 1–10 how confident are you that you would be able to quit smoking at this time? (1 = not at all confident, 10 = extremely confident). f: On a scale of 1–10 how important is it to you to quit smoking at this time? (Response: 1 = not at all important, 10 = extremely important. No other GP level variables were found to be significant in predicting 4 A’s delivery. ‘Asking’ about tobacco use occurred more frequently among patient with smoking related illness (AOR 2.07; 95\% CI 1.27, 3.37; P < 0.01). ‘Advice’ regarding the health hazards of smoking was more likely to be delivered to patients with grade school education, a smoking-related illness (AOR 2.05; 95\% CI 1.29, 3.27; P < 0.01), a positive screen for anxiety/depression (AOR 1.83; 95\% CI 1.04, 3.23; P < 0.05) and who were seen in clinic for a medical examination or prescription. ‘Assistance’ with quitting was more frequently delivered to patients with a positive Downloaded from https://academic.oup.com/eurpub/article-abstract/28/3/542/4621433 by Adam Ellsworth, Adam Ellsworth on 25 May 2018 P-value ICC 0.024 0.195 0.172 0.354 0.499 0.296 ICC: intra-class correlation coefficient, describes variation in tobacco treatment among providers sampled and is measured on a scale from 0 to 1, with a value close to 0 indicating the clusters were all similar. Intra-Provider ICC = provider variance/total variance. P values: reports on significance level of the GP-level variation observed. screen for anxiety or depression (AOR 4.67; 95\% CI 2.23, 9.75; P < 00.1). Additionally a significant (P < 0.01) trend across age groups was seen in ra ... Purchase answer to see full attachment