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PubMed2001

Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP).

A group from the European Working Party on Quality in Family Practice (EQuiP), working with over 20 European colleges of primary care, has assessed what, in their view, is needed to improve the quality of care at the interface between general practice and specialists. Experiences and ideas from a wide range of people were gathered through focused group discussions. From these it was clear that, for real improvement at the interface of care, changes are needed in the system of care and in the ways that doctors view their roles and their performance. All providers of care need to be able to see the care system from the patients' perspective if they are to help their patients make sense of and benefit from an increasingly complex system. This paper outlines the EQuiP recommendations on how cooperation between general practitioners and specialists might be improved. This includes strategic perspectives and both targets for improvement and methods for teaching, training and development that are all independent of country and health care system. The 10 targets for development identified by the group are: leadership, initial shared care approaches, task division, mutual guidelines, patient perspective, informatics, education, team building, quality monitoring systems, and cost effectiveness. Working towards these targets could provide an effective approach to improving the cooperation between the interfaces of care. Getting effective leadership is a necessary first step as implementation of such a strategy will involve significant change. Responsibility lies primarily with the medical profession.

Continuity of Patient Care↗

PubMed2006

Pulmonary arterial hypertension in France: results from a national registry.

RATIONALE: Pulmonary arterial hypertension (PAH) is an orphan disease for which the trend is for management in designated centers with multidisciplinary teams working in a shared-care approach. OBJECTIVE: To describe clinical and hemodynamic parameters and to provide estimates for the prevalence of patients diagnosed for PAH according to a standardized definition. METHODS: The registry was initiated in 17 university hospitals following at least five newly diagnosed patients per year. All consecutive adult (> or = 18 yr) patients seen between October 2002 and October 2003 were to be included. MAIN RESULTS: A total of 674 patients (mean +/- SD age, 50 +/- 15 yr; range, 18-85 yr) were entered in the registry. Idiopathic, familial, anorexigen, connective tissue diseases, congenital heart diseases, portal hypertension, and HIV-associated PAH accounted for 39.2, 3.9, 9.5, 15.3, 11.3, 10.4, and 6.2% of the population, respectively. At diagnosis, 75% of patients were in New York Heart Association functional class III or IV. Six-minute walk test was 329 +/- 109 m. Mean pulmonary artery pressure, cardiac index, and pulmonary vascular resistance index were 55 +/- 15 mm Hg, 2.5 +/- 0.8 L/min/m(2), and 20.5 +/- 10.2 mm Hg/L/min/m(2), respectively. The low estimates of prevalence and incidence of PAH in France were 15.0 cases/million of adult inhabitants and 2.4 cases/million of adult inhabitants/yr. One-year survival was 88% in the incident cohort. CONCLUSIONS: This contemporary registry highlights current practice and shows that PAH is detected late in the course of the disease, with a majority of patients displaying severe functional and hemodynamic compromise.

Adolescent↗

PubMedDate not supplied

Supervision and boundaries in a combined family practice and psychiatry residency training program: the National Capital Consortium experience.

OBJECTIVES: The combined discipline of family practice and psychiatry was created in 1995. There are no established guidelines for 1) teaching residents how to integrate these two specialties, 2) providing appropriate supervision, and 3) helping residents develop personal and professional boundaries. The authors share their approach and aim to stimulate dialogue and promote the establishment of standards for combined programs. METHOD: The authors review some of the difficulties encountered in supervising family practice-psychiatry residents and the rationale for their approach. RESULTS: Providing residents with clear boundaries of practice and supervision that initially separate the two specialties during training facilitates the development of specialty knowledge and skills as well as the capacity to form clear boundaries. CONCLUSION: Our experience suggests that only when residents learn the appropriate practice and boundaries of each specialty can they successfully integrate the two without boundary or role confusion.

Education↗

PubMed1997

Sharing psychiatric care with primary care physicians: the Toronto Doctors Hospital experience (1991-1995).

OBJECTIVES: To investigate the shared mental health care experience of the psychiatry department of a small urban general hospital, which serves an ethnoculturally diverse population. METHODS: A chart survey was undertaken of all patients referred by community physicians to a new shared care program between January 1991 and December 1995. Selected demographic and diagnostic characteristics were collected and analyzed. RESULTS: Seven hundred and thirteen patients were assessed. They were principally female, ethnoculturally varied, and highly comorbid. The most striking association involved mood and substance-related disorders. CONCLUSION: The Doctors Hospital experience shows that the shared care approach can reach large numbers of patients through a multiplier effect. Additionally, this approach has the potential to enhance access for ethnoculturally varied and diagnostically complex groups.

Ambulatory Care↗

PubMed2004

International assessment of the quality of clinical practice guidelines in oncology using the Appraisal of Guidelines and Research and Evaluation Instrument.

PURPOSE: To describe the quality of oncology guidelines developed in different countries. METHODS: The Appraisal of Guidelines and Research and Evaluation (AGREE) Instrument was used to assess the quality of 100 guidelines (including 32 oncology guidelines) from 13 countries. The criteria of the instrument are grouped into six quality domains: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence. RESULTS: Oncology guidelines had significantly higher scores on rigor of development than nononcology guidelines (42.2% v 29.4%; P =.02). In particular, systematic methods to search for evidence were more often used (P =.01); the methods for formulating the recommendations were more clearly described (P =.02); and health benefits, risks, and side effects were more often considered in formulating the recommendations (P =.03). Although the standardized scores for the other domains were not significantly different, the oncology guidelines had significantly higher scores for items measuring inclusion of all relevant professional groups (P =.05), consideration of patient views (P =.04), and presentation of different options (P =.05). Only three organizations producing oncology guidelines had standardized scores more than 60% for more than three domains. CONCLUSION: The quality of clinical practice guidelines (CPGs) is modest in general, but for certain domains, oncology guidelines seem to be of better quality than others. The experience of the organization may explain higher scores for some items. Research projects and training aimed at improving the quality of guidelines should be developed. The AGREE instrument could provide a basis for defining steps in a shared development approach to produce high-quality CPGs.

Evidence-Based Medicine↗

PubMed2003

Identification of a novel SCA14 mutation in a Dutch autosomal dominant cerebellar ataxia family.

OBJECTIVE: To report a Dutch family with autosomal dominant cerebellar ataxia (ADCA) based on a novel mutation in the PRKCG gene. METHODS: The authors studied 13 affected members of the six-generation family. After excluding the known spinocerebellar ataxia (SCA) genes, a combination of the shared haplotype approach, linkage analysis, and genealogic investigations was used. Exons 4 and 5 of the candidate gene, PRKCG, were sequenced. RESULTS: Affected subjects displayed a relatively uncomplicated, slowly progressive cerebellar syndrome, with a mean age at onset of 40.8 years. A focal dystonia in two subjects with an onset of disease in their early 20s suggests extrapyramidal features in early onset disease. Significant linkage to a locus on chromosome 19q was found, overlapping the SCA-14 region. Based on the recent description of three missense mutations in the PRKCG gene, located within the boundaries of the SCA-14 locus, we sequenced exons 4 and 5 of this gene and detected a novel missense mutation in exon 4, which involves a G-->A transition in nucleotide 353 and results in a glycine-to-aspartic acid substitution at residue 118. CONCLUSION: A SCA-14-linked Dutch ADCA family with a novel missense mutation in the PRKCG gene was identified.

Adult↗

PubMed2005

Practical management of the intersex infant.

Intersex occurs when the appearance of the internal or external genitalia is at variance with normal development for either sex. The first question asked by, and of new parents in relation to their offspring is often "Is it a boy or a girl"? A rational approach, based on knowledge of normal prenatal sexual development, and based on a careful physical examination to guide further investigation, is required to reach a diagnosis. We briefly review prenatal sexual development to provide a background to the assessment of genital ambiguity in the newborn. Aspects of physical examination are discussed in detail, with reference to published normative data where possible. We provide a classification of genital ambiguity and an approach to differential diagnosis. We highlight some of the many syndromes associated with genital ambiguity, with reference to their genetic basis where possible. In 46,XX individuals, the commonest cause of genital ambiguity is congenital adrenal hyperplasia due to 21-hydroxylase deficiency; however, in 46,XY individuals the differential diagnosis is wide, and may remain unexplained, even after extensive investigation. Two algorithms are presented, one of which provides an initial approach based on the presence of a uterus and palpable gonads alone, and a second illustrating a comprehensive differential diagnosis of the undervirilised 46,XY individual. We discuss our approach to sharing information on the diagnosis and management with the parents and highlight the early involvement of an experienced multidisciplinary team. Finally, we consider current controversial issues relating to gender assignment and management of genital ambiguity.

Chromosome Aberrations↗

PubMed2005

Supported employment for people with co-occurring disorders.

Research shows that people with dual disorders (i.e., a co-occurring mental illness and substance use disorder) are successful in supported employment programs and that employment can be a crucial step in their recovery. Based on experience observing supported employment services for 15 years, we propose practice guidelines for people with dual disorders. Successful programs share several approaches: 1) encourage employment, 2) understand substance abuse as part of the vocational profile, 3) find a job that supports recovery, 4) help with money management, and 5) use a team approach to integrate mental health, substance abuse, and vocational services.

Comorbidity↗

PubMed2006

The chemically elegant proton pump inhibitors.

Medicinal chemistry instruction at Creighton University is designed to provide an in-depth scientifically grounded and clinically relevant learning experience for pharmacy students. Each topic covered in the 2-semester required course sequence is selected based on the general utility of the compounds in question and/or the therapeutic importance of the drugs in treating life-threatening diseases. All lessons provided to campus- and Web-based students by the author are in the form of a descriptive and conversational narrative and course requirements are in place to assure that students read the lesson prior to the class period in which it is discussed. Learning tools and aids are provided to help students more readily discern the most critical aspects of each lesson, to practice required critical thinking and structure analysis skills, and to self-assess competency in meeting specific learning objectives. This manuscript illustrates this approach by sharing a lesson on the chemistry and clinically relevant structure-activity relationships of proton pump inhibitors.

Education, Pharmacy↗

PubMed1998

A hospital information system based on Common Object Request Broker Architecture (CORBA) for exchanging distributed medical objects--an approach to future environment of sharing healthcare information.

Tightly related subsystems in a HIS have to exchange medical data flexibly by the data object rather than by the battery of the data. We developed a CPR subsystem based on Common Object Request Broker Architecture (CORBA) that retrieves and stores clinical information in the object-oriented database via Internet Intra-ORB Protocol (IIOP). The system is hybridized with the legacy HIS applications on the client terminals. We believe that our solution and the experiences will contribute to the future CORBA-based environment in which computerized patient information is shared among hospitals, clinics, and tightly related systems.

Computer Communication Networks↗

PubMed2000

Reducing teen pregnancy in Oklahoma: focusing on older teens (18-19 years old).

Births to females aged 18 and 19 account for two-thirds of teen births in Oklahoma annually. It is important for Oklahoma to identify effective ways to reduce births to this age group. Nationally and locally, there are few prevention programs and little data. Oklahoma has the opportunity to lead the nation in reducing births to older teens by aggressively addressing the issue, sharing promising approaches, and building prevention efforts that include older teens in meaningful ways.

Adolescent↗

PubMed2001

The North Dublin Diabetes Shared Care (DiSC) Project: a profile of current diabetes care in Ireland.

The DiSC Project aims to assess the feasibility, effectiveness and costs of diabetes shared care in Ireland. Baseline results provide a profile of diabetes care in Ireland. Thirty general practices are participating in this randomised controlled trial. Outcomes include biophysical and psychosocial measures. The majority of patients agreed to participate in diabetes shared care. Data was collected from 183 patients with type 2 diabetes. The mean age of the patients is 65 years, 56% are male and 63% are GMS eligible. The mean HBA1c was 6.8% though 21% of patients had a HBA1c>8%. The majority of patients had a blood pressure, total cholesterol and body mass index above recommended guidelines. Only half the patients are attending a dietician or a chiropodist. The majority of patients have good glycaemic control but poor blood pressure and cholesterol control. The full trial results will determine if a shared care approach can improve clinical and psychosocial outcomes for patients.

Adult↗

PubMed1993

Promoting WID in Jordan.

Founded in 1977, the Queen Alia Fund (QAF) has been promoting social development in Jordan for 15 years by providing social services, and educational and vocational training at the grassroots. The fund, which is the country's principal nongovernmental organization (NGO), operates a network of over 40 community development centers. Under its women's programs, the fund targets such areas as literacy, health, skill training, family planning (FP) and the environment. Princess Basma Bint Talal, chairperson, QAF, introduced the activities of the fund and expressed concern for population issues in Jordan during a meeting with JOICFP Deputy Executive Director Yasuo Kon on October 13 in Tokyo. "Jordan has a very high birthrate and rapid population expansion," she said. "This places very big burdens on services; so we are now very concerned with trying to relieve this situation." Noting that FP is a very sensitive issue in Jordan. Princess Basma said that a program for birth spacing had recently been adopted nationally. She added that both JOICFP and QAF shared many mutual priorities in their approaches including a shared emphasis on health education activities. "We'd very much like to see a fostering and promoting of relations between Japanese and Jordanian NGOs, particularly in this field, and we would be delighted if we could explore the possibility of further cooperation through some of the services we offer in Jordan in this regard," she said.

Asia↗

PubMed2003

Curriculum evaluation of ethical reasoning and professional responsibility.

This exploratory study evaluated curricular content and evaluation mechanisms related to ethics and professionalism in the baccalaureate dental hygiene program at Idaho State University. Competency-based education requires enhanced student preparation in ethical reasoning, critical thinking, and decision-making. Graduates must integrate concepts, beliefs, principles, and values to fulfill ethical and professional responsibilities. Methods included 1) development of five supporting competencies defining ethics and professionalism to provide a framework for curricular evaluation; 2) assessment of all course content and evaluation methods for each supporting competency; 3) evaluation of students' clinical performance based on professional judgment grades; and 4) survey of junior (n=30) and senior (n=27) students' attitudes about dental hygiene practice related to ethics and professionalism. Results revealed that most courses include content and evaluation related to at least one supporting competency; however, authentic evaluation is weak. Clinical instructors rarely relate evaluations to ethical principles or values. Surveys showed significant differences between junior and senior students' attitudes about ethics and professionalism in six of thirty-four areas (the six were laws and regulations; communication and interpersonal skills; problem solving; professional activities/programs; integrity; and safe work environment). This article shares one approach for evaluating curricular content and evaluation methods designed to develop student competence in ethical reasoning and professionalism. Based upon the study's findings, recommendations are made for curricular enhancement via authentic evaluation and faculty training.

Adolescent↗

PubMed1992

Respiratory syncytial virus: a pediatric nursing plan of care.

Thirty-three pediatric cases of respiratory syncytial viral (RSV) infections were treated at Providence Hospital's Pediatric Intensive Care Unit (PICU), Anchorage, AK, between September 1987 and March 1988. Our 8-bed PICU nursing and respiratory therapy staff learned effective techniques in caring for patients with RSV. Our aim in this article is to share our approach in providing comprehensive care for patients with RSV infections.

Humans↗

PubMedDate not supplied

Guidelines for selecting a nursing model for practice.

Nursing models can provide direction to the practicing nurse. In this article, the process of selecting a nursing model is outlined. Noteworthy is the need for administrative support in this process in terms of providing release time, adequate coverage of the unit, scheduling, secretarial support, praise, and encouragement. It is suggested that nurses from various levels form an ad hoc committee so that there be representatives from both management and staff nurses as well as those who have been exposed to the use of models on the committee. Initially, the committee members should examine beliefs about nursing, the client, and the environment so that the model selected will reflect the beliefs and goals of the staff. Factors to consider in model selection are outlined so that the selected model will provide direction to each phase of the nursing process. Once a model is selected, it is recommended that individuals with experience in using it be approached to share their successes and difficulties. It is imperative that staff nurses be involved in the decision-making process.

Decision Making, Organizational↗

PubMed1995

Shared care between general practitioners and urologists in the management of benign prostatic hyperplasia: a survey of attitudes among clinicians.

Recent community-based population surveys have revealed a much greater prevalence of benign prostatic hyperplasia than previously suspected. From these data it has been projected that there may be more than 2 million men in the UK whose quality of life is to some extent impaired by this disorder. Since there are only 330 fully trained urologists in this country it will not be feasible for every individual presenting with prostatism to be assessed by a specialist. In an attempt to provide a more rational basis from which family practitioners can decide whether or not to refer a patient for a specialist opinion a 'shared care' flow diagram was developed and assumptions contained within field tested by means of a postal questionnaire which was sent to 2020 urologists, family practitioners and other interested clinicians. There was general agreement with most of the precepts set out in the flow diagram, the main exception was a rejection of the suggestion that every patient with prostatism should have a prostate-specific antigen level determined before referral. We conclude that there seems a consensus among respondents that a shared care approach to the management of BPH may both improve the standard of care provided in this area by family practitioners and allow hard pressed urologists to focus greater attention on those patients whose conditions require surgical expertise to resolve.

Attitude of Health Personnel↗

PubMed1995

Acute pancreatitis. Surgical management.

In general, the best approach to pancreatitis is to recognize its presence early, resuscitate the patient aggressively, and employ nutritional and medical therapy to avoid complications. Nonetheless, either because of trauma or failure of medical therapy, some patients develop complications (e.g., hemorrhagic or necrotizing pancreatitis, abscess, pseudocyst, or fistula) that require operative intervention. Expert surgical judgment is required to decide which patients require surgery, when to operate, and what operation(s) to perform. Many of these patients require multiple surgical procedures and are critically ill, requiring careful attention to nutritional support, ventilatory management, and surveillance for sepsis. The care of these patients requires a multidisciplinary approach involving personnel in internal medicine, gastroenterology, radiology, surgery, anesthesiology, and nursing. Pancreatitis does not respect the boundaries of class, race, creed, gender, or traditional specialty interests; only by using a collegial approach, which shares expertise in a multidisciplinary fashion, is it possible to optimize patient care and salvage critically ill patients with this deadly disease.

Acute Disease↗