Mixed-method analysis of screening for Strongyloides stercoralis prior to immunosuppression: a problem of limited bandwidth?
Strongyloides stercoralis
immunocompromised
preventative health
screening
Journal
Internal medicine journal
ISSN: 1445-5994
Titre abrégé: Intern Med J
Pays: Australia
ID NLM: 101092952
Informations de publication
Date de publication:
05 2022
05 2022
Historique:
revised:
12
07
2020
received:
07
05
2020
accepted:
15
07
2020
pubmed:
21
7
2020
medline:
14
5
2022
entrez:
21
7
2020
Statut:
ppublish
Résumé
Guidelines recommend screening for strongyloidiasis prior to immunosuppression in those at epidemiological risk, as hyperinfection following immunosuppression is often fatal. The uptake of this recommendation is unknown and we aimed to explore this in our setting. To determine the proportion of adult patients at epidemiological risk for strongyloidiasis who were screened prior to immunosuppression at the Royal Melbourne Hospital, and to explore the factors that influenced clinicians' decision to screen for strongyloidiasis prior to immunosuppression. This study used a mixed-methods approach. First, a 12-month (1 January 2018 to 1 January 2019) retrospective observational study was used to quantify the proportion of those at epidemiological risk who were screened prior to immunosuppression, while also identifying variables that were positively or negatively associated with screening. Second, clinicians from relevant specialties were recruited for focus group sessions to explore factors that influenced their decision to screen according to an interpretivist framework. A total of 230 newly immunosuppressed patients at epidemiological risk of strongyloidiasis were identified, of whom 87 (37.8%) were screened prior to immunosuppression. In multivariate analysis, older patients, outpatients and people from non-English-speaking backgrounds were significantly less likely to be screened. In focus groups, several barriers and enablers to screening were identified. Notably, clinicians reported that a major barrier was the cognitive load required to clinically reason about this uncommon disease, in addition to other priorities. We identified many missed opportunities to screen patients at risk of hyperinfection, particularly those most vulnerable. To improve screening, this study highlights the importance of reducing cognitive load by using decision-support tools, which may facilitate screening in vulnerable patients and in time-constrained settings.
Sections du résumé
BACKGROUND
Guidelines recommend screening for strongyloidiasis prior to immunosuppression in those at epidemiological risk, as hyperinfection following immunosuppression is often fatal. The uptake of this recommendation is unknown and we aimed to explore this in our setting.
AIMS
To determine the proportion of adult patients at epidemiological risk for strongyloidiasis who were screened prior to immunosuppression at the Royal Melbourne Hospital, and to explore the factors that influenced clinicians' decision to screen for strongyloidiasis prior to immunosuppression.
METHODS
This study used a mixed-methods approach. First, a 12-month (1 January 2018 to 1 January 2019) retrospective observational study was used to quantify the proportion of those at epidemiological risk who were screened prior to immunosuppression, while also identifying variables that were positively or negatively associated with screening. Second, clinicians from relevant specialties were recruited for focus group sessions to explore factors that influenced their decision to screen according to an interpretivist framework.
RESULTS
A total of 230 newly immunosuppressed patients at epidemiological risk of strongyloidiasis were identified, of whom 87 (37.8%) were screened prior to immunosuppression. In multivariate analysis, older patients, outpatients and people from non-English-speaking backgrounds were significantly less likely to be screened. In focus groups, several barriers and enablers to screening were identified. Notably, clinicians reported that a major barrier was the cognitive load required to clinically reason about this uncommon disease, in addition to other priorities.
CONCLUSIONS
We identified many missed opportunities to screen patients at risk of hyperinfection, particularly those most vulnerable. To improve screening, this study highlights the importance of reducing cognitive load by using decision-support tools, which may facilitate screening in vulnerable patients and in time-constrained settings.
Types de publication
Journal Article
Observational Study
Langues
eng
Sous-ensembles de citation
IM
Pagination
790-799Informations de copyright
© 2020 Royal Australasian College of Physicians.
Références
Puthiyakunnon S, Boddu S, Li Y, Zhou X, Wang C, Li J et al. Strongyloidiasis - an insight into its global prevalence and management. PLoS Negl Trop Dis 2014; 8: e3018.
Miller A, Young EL, Tye V, Cody R, Muscat M, Saunders V et al. A community-directed integrated Strongyloides control program in Queensland, Australia. Trop Med Infect Dis 2018; 3: 48.
Olsen A, van Lieshout L, Marti H, Polderman T, Polman K, Steinmann P et al. Strongyloidiasis - the most neglected of the neglected tropical diseases? Trans R Soc Trop Med Hyg 2009; 103: 967-72.
Ravanini P, Huhtamo E, Hasu E, Rosa F, Costantino S, Crobu MG et al. Strongyloidiasis in man 75 years after initial exposure. Emerg Infect Dis 2011; 17: 931-2.
Greaves D, Coggle S, Pollard C, Aliyu SH, Moore EM. Strongyloides stercoralis infection. Br Med J 2013; 347: f4610.
Buonfrate D, Requena-Mendez A, Angheben A, Muñoz J, Gobbi F, Ende J et al. Severe strongyloidiasis: a systematic review of case reports. BMC Infect Dis 2013; 13: 78.
Lam CS, Tong MKH, Chan KM, Siu YP. Disseminated strongyloidiasis: a retrospective study of clinical course and outcome. Eur J Clin Microbiol Infect Dis 2006; 25: 14-8.
Ghosh K, Ghosh K. Strongyloides stercoralis septicaemia following steroid therapy for eosinophilia: report of three cases. Trans R Soc Trop Med Hyg 2007; 101: 1163-5.
Mejia R, Nutman TB. Screening, prevention, and treatment for hyperinfection syndrome and disseminated infections caused by Strongyloides stercoralis. Curr Opin Infect Dis 2012; 25: 458-63.
Mobley CM, Dhala A, Ghobrial RM. Strongyloides stercoralis in solid organ transplantation. Curr Opin Organ Transplant 2017; 22: 336-44.
Antibiotic Expert Groups. Strongyloides stercoralis prophylaxis in immunocompromised adults without HIV infection. In: Therapeutic Guidelines: Antibiotic. Version 16. Melbourne: Therapeutic Guidelines Limited; 2019.
Muñoz J, Gomez-Junyent J, Bisoffi Z, Buonfrate D, Zammarchi L, Requena-Méndez A. Evidence-based guidelines for screening and management of strongyloidiasis in non-endemic countries. Am J Trop Med Hyg 2017; 97: 645-52.
Agbata EN, Morton RL, Bisoffi Z, Bottieau E, Greenaway C, Biggs B-A et al. Effectiveness of screening and treatment approaches for schistosomiasis and strongyloidiasis in newly-arrived migrants from endemic countries in the EU/EEA: a systematic review. Int J Environ Res Public Health 2019; 16: 11.
Caruana SR, Kelly HA, Ngeow J, Ryan NJ, Bennett CM, Chea L et al. Undiagnosed and potentially lethal parasite infections among immigrants and refugees in Australia. J Travel Med 2006; 13: 233-9.
Einsiedel L, Spelman D. Strongyloides stercoralis: risks posed to immigrant patients in an Australian tertiary referral centre. Intern Med J 2006; 36: 632-7.
Chowdhury MF. Interpretivism in aiding our understanding of the contemporary social world. Open J Philos 2014; 2014: 432-8.
Stalmeijer RE, McNaughton N, Van Mook WN. Using focus groups in medical education research: AMEE guide no. 91. Med Teach 2014; 36: 923-39.
Braun V, Clarke V. Thematic analysis. In: Cooper H, Camic PM, Long DL, Panter AT, Rindskopf D, Sher KJ, eds. APA Handbook of Research Methods in Psychology, Vol 2: Research Designs: Quantitative, Qualitative, Neuropsychological, and Biological. Washington, DC: American Psychological Association; 2012; 57-71.
Young JQ, Merrienboer J, Durning S, Cate O. Cognitive load theory: implications for medical education: AMEE guide no. 86. Med Teach 2014; 36: 371-84.
Merriënboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ 2010; 44: 85-93.
Qiao Y, Shen J, Liang X, Ding S, Chen F, Shao L et al. Using cognitive theory to facilitate medical education. BMC Med Educ 2014; 14: 79.
Shachak A, Hadas-Dayagi M, Ziv A, Reis S. Primary care physicians' use of an electronic medical record system: a cognitive task analysis. J Gen Intern Med 2009; 24: 341-8.
Hicks P, Huckson S, Fenney E, Leggett I, Pilcher D, Litton E. The financial cost of intensive care in Australia: a multicentre registry study. Med J Aust 2019; 211: 324-5.
Cass A, Chadban S, Gallagher M, Howard K, Jones A, McDonald S et al. The Economic Impact of End-Stage Kidney Disease in Australia: Projections to 2020. Melbourne: Kidney Health Australia; 2010.
Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health C 2007; 19: 60-7.
Guirgis M, Nusair F, Bu YM, Yan K, Zekry AT. Barriers faced by migrants in accessing healthcare for viral hepatitis infection. Intern Med J 2012; 42: 491-6.
Suurmond J, Uiters E, de Bruijne MC, Stronks K, Essink-Bot M-L. Explaining ethnic disparities in patient safety: a qualitative analysis. Am J Public Health 2010; 100(Suppl 1): S113-7.
Boulware DR, Stauffer WM, Hendel-Paterson BR, Rocha JLL, Seet RC-S, Summer AP et al. Maltreatment of Strongyloides infection: case series and worldwide physicians-in-training survey. Am J Med 2007; 120: 545.e1-8.
Chaves NJ, Paxton GA, Biggs B, Thambiran A, Gardiner J, Williams J et al. The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline. Med J Aust 2017; 206: 310-5.
Leydon J, Jolley D, Biggs B-A, Mihrshahi S, Nuon S, Caruana S et al. Management of chronic strongyloidiasis in immigrants and refugees: is serologic testing useful? Am J Trop Med Hyg 2009; 80: 788-91.
Zweck N, Krause V, Huffam S, Anstey N, Selva-Nayagam S, Currie B et al. Prevention of opportunistic infections in immunosuppressed patients in the tropical top end of the Northern Territory of Australia. Commun Dis Intell Q Rep 2003; 27: 526.
Belzile JA, Öberg G. Where to begin? Grappling with how to use participant interaction in focus group design. Qual Res 2012; 12: 459-72.