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PubMed2004

Implementing buprenorphine treatment in community settings in Australia: experiences from the Buprenorphine Implementation Trial.

Buprenorphine was registered in Australia as a maintenance and detoxification agent for the management of opioid dependence in November, 2000, and became widely available in August, 2001. This paper provides an overview of key developments in the introduction of buprenorphine treatment in Australia, with an emphasis upon the delivery of services in community-based (primary care) settings. A central study in this work was the Buprenorphine Implementation Trial (BIT), a randomized, controlled trial comparing buprenorphine and methadone maintenance treatment delivered under naturalistic conditions by specialist and community-based service providers (general practitioners and community pharmacists) in 139 subjects across nineteen treatment sites. In addition to conventional patient outcome measures (treatment retention, drug use, psychosocial functioning, and cost effectiveness), the BIT study also involved the development and evaluation of clinical guidelines, training programs for clinicians, and client literature, which are described here. Integration of treatment systems (methadone with buprenorphine, specialist and primary-care programs) and factors thought to be important in the uptake of buprenorphine treatment in Australia since registration are discussed.

Adolescent↗
PubMed2004

Medication-related problems commonly occurring in an Australian community setting.

PURPOSE: This study characterised medication-related problems in 1000 Australian patients living in the community, and who were considered at risk of medication misadventure. METHODS: A review was undertaken of 1000 clinical case notes, developed during the delivery of medication management reviews. Patient demographics, medications used, medical conditions and medication-related problems were categorised according to established classification systems. Descriptive analyses were undertaken. RESULTS: Overall, 2222 problems were identified. Ninety per cent of patients had at least one medication-related problem. One in three people were found to require additional monitoring, one in four required additional medication, one in four were using the wrong or inappropriate medication and one in five were using insufficient medication. Cardiovascular, nervous system, alimentary and respiratory medicines were most commonly implicated, accounting for 69% of the medication-related problems. CONCLUSION: This analysis reveals the need for ongoing vigilance of, and support for, people at high risk of medication misadventure. This information is also useful for informing the design of public health or health promotion strategies aiming to reduce the prevalence of these problems.

Aged↗
PubMed2002

A pilot study of oncology staff perceptions of palliative care and psycho-oncology services in rural and community settings in Indiana.

Although there has been an increased interest in health care delivery for rural community populations, concerns remain regarding the lack of access to primary health care and specialty services (such as palliative care), particularly in rural areas that are medically underserved (MU). This survey was conducted to examine the perceptions of palliative care services in rural communities and toward identifying perceived barriers that interfere with accessing palliative care services. In conducting the study, personnel from various disciplines throughout the Community Cancer Care (CCC) network (the largest private provider of oncology services in Indiana) completed a survey that assessed their perceptions of the strengths and weaknesses of the available palliative care services in their communities. These responses, which indicate discrepancies in perceptions among staff within sites, suggest problems of integration of palliative care in given locations. Results revealed three particularly problematic areas: accessing pain control, accessing psychological or psychiatric services or both, and overcoming barriers to hospice care. Although no significant differences were found for any variables between MU and adequately medically served (AMS) areas, in general palliative care is limited and unintegrated into oncology care. Confusion among staff at a particular oncology program likely contributes to the haphazard delivery and poor integration of palliative care. Conclusions are tempered by important study limitations but the results suggest the need for programs that improve delivery of palliative care in rural Indiana.

Analysis of Variance↗
PubMed2004

Two major hospitals can share level I status in a rural community setting.

BACKGROUND: Even though development of Level I trauma centers is thought to improve outcome of injury treatment, the political barriers in communities where two capable hospitals compete for designation can be formidable. This report documents the initial experience of a Level I trauma center developed in a two-hospital setting whereby each hospital hosted the trauma center on an alternating annual basis. METHODS: Preliminary efforts began with a community-based report on trauma care to which both hospitals and their associated school of medicine contributed. In addition to confirming need, all parties agreed to develop a single Level I trauma center that would be verified by the appropriate state agency and would receive professional and financial support from all three institutions. RESULTS: The Southern Illinois Trauma Center began to function on July 1, 1999. Prehospital acceptance of the community agreement has resulted in appropriate triage to the designated hospital in 95% of the 1,000 cases seen annually. Integration of trauma care into the surgical residency program has been valuable both for function of the trauma center and as a teaching enhancement for trauma and critical care as reflected by significantly improved American Board of Surgery In-Training Examination scores. The trauma center is governed by a trauma committee with representation from the three institutions. The percentage of trauma transfers has increased over 3 years from 23% to 28%. Four annual institutional site changeovers have now occurred without incident or disruption of service. The trauma center finances are reviewed by the participants on a biannual basis and have been deemed favorable. CONCLUSION: The community medical resources are commonly polarized between two large hospitals but need not prevent centralized trauma center development if preagreed community support can be achieved. Annual site change is not an impediment and could be successfully used in other similar communities, provided they are receptive to the concept of sharing Level I trauma center site designation.

Community Health Services↗
PubMed2001

Determinants of compliance with nasal continuous positive airway pressure treatment applied in a community setting.

Objectives: To assess determinants of nasal continuous positive airway pressure (CPAP) compliance when applied in a community setting.Background: One-third of obstructive sleep apnea patients eventually refuse CPAP therapy. Treatment outcomes may be improved by identifying predictors of CPAP failure, including whether management by primary care physicians without sleep consultation affects results.Methods: Polysomnogram, chart review, and questionnaire results for regular CPAP users (n=123) were compared with those returning the CPAP machine (n=26).Results: Polysomnographic data and the presence of multiple sleep disorders were only modestly predictive of CPAP compliance. Striking differences in questionnaire responses separated CPAP users from non-users, who reported less satisfaction with all phases of their diagnosis and management. Rates of CPAP use were not significantly different between patients managed solely by their primary care physician or by a sleep consultant.Conclusions: Polysomnographic findings are unlikely to identify eventual CPAP non-compliers in a cost-effective fashion. Improvements in sleep apnea management may result from addressing the role of personality factors and multiple sleep disorders in determining compliance. In this practice setting, management by primary care physicians did not significantly degrade CPAP compliance.

Journal Article↗
PubMedDate not supplied

A case study using larval therapy in the community setting.

This article discusses the use of larval therapy by district nurses in wound bed preparation in the community. A case study is presented of a patient with a persistently necrotic and painful anterior tibial wound post-fasciotomy. The case study offers an insight into the practicalities involved in the use of larvae as effective and safe debriders of tissue for wound bed preparation. It is concluded that larval therapy is an underused and misunderstood resource when considering effective wound care and this treatment should be actively considered as an alternative therapy in wound care. There is a need for both qualitative and quantitative research in this field, enabling a more thorough discussion to be entered into by all practitioners with an interest in this subject.

Aged↗
PubMed2001

The disability profile of patients with schizophrenia in psychiatric hospital and community settings in Singapore.

The disability profile of persons with schizophrenia in Singapore and how disability levels vary in patients cared for in the community and in the long-stay wards of a state mental hospital were studied using the Life Skills Profile (LSP). The inter-rater reliability of the LSP assessed by the intraclass correlation coefficient (ICC), was lower than in the Australian studies. The test-retest ICCs for the total LSP score and the five subscale scores were satisfactory for the hospitalised subjects and for the community psychiatric nurse subjects, but generally poor for the community care facility subjects. The average ICCs were lower compared to the Australian study. Female hospitalised subjects but not male hospitalised subjects returned higher disability scores on all LSP scales compared to community subjects. This study provided some preliminary data on the usefulness and validity of the LSP in a multi-ethnic Asian setting like Singapore. If the LSP is used as a measure of disability in schizophrenia, it would appear that ratings should only be made by those who know the subject well, and that raters should be formally trained mental health professionals.

Community Mental Health Centers↗
PubMedDate not supplied

The nature of health promotion in acute and community settings.

Since the late 1980s, there has been a consistent call from nursing's advisory and legislative bodies to incorporate the discipline of health promotion into the nursing profession. On reflection, however, evidence indicates that despite these calls there has not been a universal uptake of health promotional activity into the profession. What is evident is that where health promotional activity does take place, it occurs more in the community than in the acute setting. This article sets out to explore the reasons for this. It suggests that certain current and future activities may help to further promote the universal adoption of health promotion within nursing practice.

Acute Disease↗
PubMed1989

1989 ARRS President's Award. The validity and utility of sonography in the diagnosis of appendicitis in the community setting.

Two hundred six patients with suspected appendicitis were examined with sonography over a 6-month period in three community teaching hospitals. Of 41 patients in whom the surgeons judged the clinical findings severe enough to warrant immediate surgery (group A), 34 (83%) had appendicitis, and sonography had a sensitivity of 0.76, a specificity of 0.71, and an accuracy of 0.76. Of 165 patients in whom the surgeons judged the clinical findings severe enough to warrant hospitalization for observation but not immediate surgery (group B), 51 (31%) had appendicitis at subsequent surgery. Sonography had a sensitivity of 0.96, a specificity of 0.94, and an accuracy of 0.95. Of 49 surgeons surveyed, the mean testing threshold (i.e., the probability of appendicitis below which they would send the patient home without further tests or observation) was 0.11, and the mean treatment threshold (i.e., the probability of appendicitis above which they would operate immediately) was 0.82. The posttest probability of appendicitis with findings indicating appendicitis present on sonography was 0.93 in group A and 0.88 in group B, and with findings absent on sonography it was 0.62 in group A and 0.02 in group B. We conclude that in group A patients, the use of sonography remains controversial in the diagnosis of appendicitis, but in group B patients it is both valid and useful.

Appendicitis↗