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PubMed1986

Health care in transition. Consequences for young physicians. Council on Long-Range Planning and Development.

Individuals planning for a career in medicine must weigh a number of factors into their decisions. Increasingly, they must understand the nature of the socioeconomic environment of health care, including the extent of competition with other physicians and other health professionals; the degree of autonomy from health care institutions, government, and third-party payers; the impact of demographic or technological changes; and the economics of medical practice. This report analyzes the environment of medicine, emphasizing those elements that will be most important to medical students and resident physicians. It focuses on three stages of a physician's career: obtaining a medical education, beginning to practice medicine, and maintaining a viable practice.

Adolescent↗
PubMedDate not supplied

Move from patient-focused care model to point-of-care testing: transitioning of laboratory services.

During the past several years, the Clinical Laboratories of the Lee Memorial Health System (LMHS) have been involved extensively in adjusting the delivery systems for the provision of clinical laboratory services as the industry, competitive market, and health system moved through periods of rapid transition. This environment has allowed the opportunities for laboratory services to be provided through a variety of delivery models: central laboratory, point-of-service testing, and point-of-care testing. The Orthopedic Center at Lee Memorial Hospital was designed as a patient-focused care center and operated as a "mini hospital," housing most of the services required to care for the System's orthopedic patients, including a point-of-service (decentralized) laboratory. LMHS decided to conduct a trial of hand-held chemistry analyzers in the Orthopedic Center. The analyzer's test cost and ease of operation were as expected; however, it was found that the analyzers were not appropriate for continued use in the Orthopedic Center. Responsibility for testing for the Orthopedic Center was returned to the Central Laboratory. With the exception of certain traditional point-of-care procedures, the Central Laboratories now provide laboratory services for all of the facilities' patient care areas.

Florida↗
PubMed2003

Transition of care between paediatric and adult gastroenterology. Cystic fibrosis.

Advancement in treatment has resulted in a dramatic increase in life expectancy of patients with cystic fibrosis (CF) to well beyond 30 years of age in most centres. What was once a fatal genetic disease in childhood now sees over a third of its CF populations in adult clinics. The improved survival is multifactorial, but most attribute the reasons to more aggressive nutritional care along with better management of the gastrointestinal and pulmonary systems. Many of the nutritional and GI issues of paediatric patients remain similar when they become adults, except that there is the added psychosocial stress associated with this transition. This chapter aims to highlight the gastrointestinal and nutritional issues manifesting at the different stages of life from infancy to adulthood, and the recommended management.

Adolescent↗
PubMed2005

Growing up and moving on: transition from pediatric to adult care.

The development of transitional care is one of the major challenges for the twenty-first century as the survival rates and medical outcomes for child and adolescent recipients of transplants continue to improve. Such developments must include both paediatric and adult providers and is likely to require training of professionals in both arenas. Transition is a multidimensional process with transfer to adult care, only one event within that process. The aim of this paper is to present the philosophy of transition and an evidence-based approach to transitional care in terms of the need for it, proposed models of care and the evidence of the benefits of transitional care programmes. Examples of some key clinical aspects of transitional care including communication skills, parenting, self advocacy, vocation will be presented. Adherence issues will be presented in accompanying papers in this journal. Finally, potential barriers to successful transition will be explored.

Adolescent↗
PubMed1998

Urban health care in transition: challenges facing Los Angeles County.

The authors examine the Medicaid Section 1115 Demonstration Project currently underway in Los Angeles County. The waiver was designed as part of a response to a financial crisis the Los Angeles County Department of Health Services (LACDHS) faced in 1995. It provides financial relief to give the county time to restructure its system for serving the medically indigent population. Los Angeles County's goal is to reduce its traditional emphasis on emergency room and hospital care by building an integrated system of community-based primary, specialty, and public health care. This case study describes activities completed through the spring of 1997, approximately 1 year after the waiver was approved.

Community Health Services↗
PubMed2003

Confirming the diagnosis of growth hormone deficiency (GHD) and transitioning the care of patients with childhood-onset GHD.

Growth hormone deficiency (GHD) diagnosed in childhood may persist into adult life. After attainment of final height, retesting of the patient's growth hormone-insulin-like growth factor (GH-IGF) axis using the adult GHD diagnostic criteria should be performed after an appropriate interval of 1-3 months off GH therapy. At the time of retesting, other pituitary hormones and serum IGF-I levels should also be measured. The opportunity should be taken to assess body composition, bone mineral density, and fasting lipid and insulin levels. Patients with severe, long-standing, multiple pituitary hormone deficiency, genetic defects, or severe organic GHD can be excluded from GH retesting. When the diagnosis of adult GHD is established, continuation of GH therapy can be recommended unless there is a known risk of diabetes mellitus or malignancy. The patient's transition to GH replacement in adulthood should be arranged as a close collaboration between the pediatric and adult endocrinologists, who should discuss the reinitiation of treatment with the patient.

Adult↗
PubMed2005

Evaluating immediate and long-range effect of a geriatric clerkship using reflections and ratings from participants as students and as residents.

This article describes a longitudinal study developed to assess perceived usefulness of a mandatory geriatric clerkship from the perspective of junior students completing the newly initiated program in 1998-1999 and 1999-2000 and these same students as second- or third-year residents. End-of-clerkship student evaluations were compared with follow-up resident surveys of those same students to identify the utility of information provided and strengths and weaknesses of the initial course experience. Students participated in hospice, outpatient clinics, nursing homes, and transitional care venues during their clerkship experience at the Donald W. Reynolds Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences. Two hundred eighty-five student evaluations were collected, and 143 resident surveys were returned. Quantitative and qualitative data from students and residents corroborated each other in identifying strengths and weaknesses of the clerkship. Hospice information was successfully incorporated into residency practice. In contrast, outpatient clinic, nursing home, and transitional care segments of the clerkship were perceived as inadequate. Survey responses validated faculty changes that were initiated in the following years. These changes use settings and patients that more accurately mirror those seen in typical resident encounters.

Adult↗
PubMed2004

Development of an applied cognition scale to measure rehabilitation outcomes.

OBJECTIVE: To examine the structure and content coverage of an item pool of new items based on the Activity categories from the International Classification of Functioning, Disability and Health and items from existing instruments to measure the applied cognition dimension of function. DESIGN: Prospective study. SETTING: Four postacute care rehabilitation settings (inpatient, transitional care, home care, outpatient) in an urban-suburban area of northeast United States. PARTICIPANTS: Convenience sample of 477 patients (mean age, 62.7 y) receiving rehabilitation services for neurologic, orthopedic, or complex medical conditions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants were administered applied cognition items from the new Activity Measure for Post-Acute Care, the Medical Outcomes Study 8-Item Short-Form Health Survey, and an additional setting-specific measure: the FIM instrument (inpatient rehabilitation); the Minimum Data Set (skilled nursing facility); the Minimum Data Set-Post Acute Care (postacute settings); or the Outcome Assessment and Information Set (home care). Rasch (partial-credit model) analyses were conducted to examine item fit, item coverage, scale unidimensionality, and category difficulty estimates. RESULTS: The majority of items (46/59) could be located along a single continuum. Relatively few people were performing at the lower end of the difficulty scale, and about 25% were at ceiling. CONCLUSIONS: The proposed definition of applied cognition dimension provides a useful guide for item development to measure this dimension. Further work is needed to determine how best to measure function in this domain for people at the upper and lower ends of the continuum.

Adult↗
PubMed2003

Transition of care between paediatric and adult gastroenterology. Assessment of growth and nutrition.

Growth is a dynamic process that is characterized by physiological changes in an individual from infancy into adulthood. Growth should be monitored sequentially and is an important tool in the early detection of chronic disease in children. Growth occurs in three phases: infancy, childhood and puberty (adolescence). The adequacy of nutritional status can be assessed by anthropometric measurements that include height, weight and body composition as well as laboratory evaluations. Individual patients can then be compared to normative or expected values. Impaired growth and nutritional status can be seen in a variety of gastrointestinal disorders and are described in this chapter.

Adolescent↗
PubMed2003

Transition of care between paediatric and adult gastroenterology. Liver transplantation.

With the increasing success of liver transplantation in children, a growing number of children are reaching an age when it is no longer appropriate for them to be followed by paediatricians. Clinicians looking after these liver allograft recipients need to be aware of the additional problems and needs in this group of young patients. While life after transplantation is usually near normal, a proportion of adolescents suffer from physical and psychological stresses that may result in social and behavioural problems. Non-compliance can have a major adverse impact on graft function. Immunosuppression needs to be adjusted to maintain good graft function, but also to keep to a minimum the adverse effects including renal failure and malignancy. The adverse cosmetic effects of some immunosuppressive drugs can be particularly troublesome at this stage in life. Overall, adolescent liver allograft recipients can have an excellent quality of life. Health care professionals need to be aware of the additional problems that this group of patients may have and they will need to adapt the follow-up in response to these issues.

Adolescent↗
PubMed2003

Transition of care between paediatric and adult gastroenterology. Coeliac disease.

Coeliac disease is a condition in which there is an abnormal mucosa in the small intestine. It improves with a gluten free diet, with avoidance of wheat, rye, barley and possibly oats. The history and epidemiology of this condition are discussed. Diagnosis is based on demonstrating that the characteristic histological abnormalities in the small intestine are dependent on gluten ingestion. Diagnostic pitfalls are discussed. The anti-endomysium and anti-tissue transglutaminase antibodies are specific and sensitive diagnostic tools. The wide variety of clinical symptoms and presentations are discussed including the associated condition of dermatitis herpetiformis. Failure to respond to a gluten-free diet can represent simple dietary problems, an alternative diagnosis or, occasionally, the development of a serious complication of coeliac disease such as ulcerative jejunitis or enteropathy-associated T cell lymphoma. Progress towards the characterization of the toxic epitopes within gluten that exacerbate coeliac disease and our current understanding of the genetics of the disorder are presented.

Adolescent↗
PubMed2003

Transition of care between paediatric and adult gastroenterology. Chronic viral hepatitis.

Chronic viral hepatitis is a common disease. More than 500 million people have chronic viral hepatitis worldwide. These diseases are due to chronic infection with hepatitis B virus, hepatitis D virus or hepatitis C virus. Chronic viral hepatitis is responsible for severe complications: cirrhosis and hepatocellular carcinoma, which are responsible for major morbidity and mortality worldwide. The prognosis of chronic viral hepatitis depends on the rate of progression of fibrosis, which varies widely from one patient to another. Some factors, such as gender, age, alcohol consumption and immune status, influence the progression of fibrosis. In recent years, treatment of chronic viral hepatitis has markedly improved-especially in chronic hepatitis C, with more than 50% of patients having a sustained response with the combination of pegylated interferon and ribavirin. Also, in chronic hepatitis B, new drugs are available, or being evaluated, and combination therapy could dramatically change future therapeutic strategies.

Adolescent↗
PubMed2003

Transition of care between paediatric and adult gastroenterology. Autoimmune hepatitis.

Autoimmune hepatitis (AIH) is a rare chronic disease of the liver with an excellent prognosis under medical therapy capable of reaching complete remission. The diagnosis of AIH relies on the exclusion of viral, metabolic, genetic and toxic aetiologies of chronic hepatitis, or hepatic injury. Autoantibodies contribute to the diagnosis of AIH and have led to the serological subclassification into three distinct types. Also, immunogenetic associations suggest heterogeneity of the syndrome of AIH. Treatment is not based on serological types but is uniformly employed for all subtypes of AIH. Although 90% of patients respond to treatment, immunosuppressive drugs used in transplant medicine have been employed for patients with treatment failure. New drugs, such as budenoside, are being evaluated for the long-term treatment of AIH with a reduction in steroid side-effects. Liver transplantation is an established treatment option for patients who fail to reach remission and progress to cirrhosis and liver failure. In Europe, about 4% of cirrhotic patients with the diagnosis of AIH undergo transplantation. The diagnosis and awareness of the disease is designed to reduce mortality and morbidity.

Adolescent↗
PubMedDate not supplied

California healthy and ready to work transition health care guide: developmental guidelines for teaching health care self-care skills to children.

This article presents developmental guidelines that can be used by parents and nurses for teaching children health care self-care skills. These guidelines are intended to provide a framework for instructing parents and nurses about the developmentally appropriate skills children can learn to become self sufficient in managing their own health care needs. The guidelines are based on the developmental frameworks of Piaget and Erikson and self-care models of Orem. Although general in scope, these guidelines can be individualized to the needs of each child.

Adolescent↗