Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
Department of Infectious Diseases, Alfred Hospital, Melbourne, Victoria, Australia.
Intern Med J. 2022 May;52(5):790-799. doi: 10.1111/imj.14991. Epub 2022 Mar 24.
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.
指南建议对处于流行病学风险的免疫抑制患者进行旋毛虫病筛查，因为免疫抑制后发生的重度感染通常是致命的。目前尚不清楚这一建议的接受程度，我们旨在探讨这一问题。
确定在墨尔本皇家医院，处于旋毛虫病流行病学风险的成年患者在免疫抑制前接受筛查的比例，并探讨影响临床医生在免疫抑制前筛查旋毛虫病的因素。
本研究采用混合方法。首先，进行了为期 12 个月（2018 年 1 月 1 日至 2019 年 1 月 1 日）的回顾性观察研究，以确定处于流行病学风险的患者在免疫抑制前接受筛查的比例，同时确定与筛查呈正相关或负相关的变量。其次，招募相关专业的临床医生进行焦点小组会议，根据解释主义框架探讨影响他们筛查决策的因素。
共确定了 230 例处于旋毛虫病流行病学风险的新免疫抑制患者，其中 87 例（37.8%）在免疫抑制前接受了筛查。多变量分析显示，年龄较大、门诊患者和非英语背景的患者接受筛查的可能性显著降低。在焦点小组中，确定了一些筛查的障碍和促进因素。值得注意的是，临床医生报告说，除了其他优先事项外，临床推理这种罕见疾病所需的认知负担是一个主要障碍。
我们发现了许多错失筛查高危感染患者的机会，特别是那些最脆弱的患者。为了提高筛查率，本研究强调了通过使用决策支持工具来降低认知负担的重要性，这可能有助于在脆弱患者和时间紧迫的环境中进行筛查。
