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PubMed1996

Local clinical guidelines: description and evaluation of a participative method for their development and implementation.

BACKGROUND: National guidelines are rarely followed by immediate change in clinical behaviour. We present our experience of an active educational method for local development and implementation of a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method for developing local clinical guidelines. METHODS: A trial in a district of the effect of guideline development incorporating active participation of intended recipients on subsequent relevant prescribing. It was carried out in Wirral Family Health Services Authority district (the Wirral peninsula) comprising 69 general practices covering a population of 345,763. An exemplar guideline on 'hypertension in the elderly' was developed by the method described. The principal recommended drug was bendrofluazide 2.5 mg once daily. The differences in prescribed daily doses (PDD) of bendrofluazide 2.5 mg tablets per quarter per 1000 prescribing units (age-weighted population) between the intervention district and England as a whole was measured. RESULTS: Comparison of the intervention district with England data demonstrates a median difference of 122.49 PDD before and 206.34 PDD after guideline production, this change is statistically highly significant (Mann-Whitney two-tailed P < 0.0001; 95% CI = 36.51-104.77). Grouped regression analysis shows no significant difference (0.89) in slope gradients before guideline production (P = 0.35, 95% CI = -3.97-5.76), but the difference in slope gradients after (12.95) is statistically highly significant (P < 0.0001; 95% CI = 8.17-17.73). The data suggests that the change in clinical behaviour persisted for at least two years. CONCLUSION: Participation of intended recipient general practitioners and local specialists in the development of a guideline by an active educational method as described was followed by a favourable change in clinical behaviour which persisted for at least two years.

Aged↗

PubMed1998

Managed care and the delivery of primary care to the elderly and the chronically ill.

OBJECTIVE: To analyze primary care staffing in HMOs and to review the literature on primary care organization and performance in managed care organizations, with an emphasis on the delivery of primary care to the elderly and chronically ill. DATA SOURCES/STUDY SETTING: Analysis of primary care staffing: InterStudy HMO census data on primary care (n = 1,956) and specialist (n = 1,777) physician staffing levels from 1991 through 1995. Primary care organization and performance for the chronically ill and elderly were analyzed using a review of published research. STUDY DESIGN: For the staffing-level models, the number of primary care and specialist physicians per 100,000 enrollees was regressed on HMO characteristics (HMO type [group, staff, network, mixed], HMO enrollment, federal qualification, profit status, national affiliation) and community characteristics (per capita income, population density, service area size, HMO competition). For the review of organization and performance, literature published was summarized in a tabular format. PRINCIPAL FINDINGS: The analysis of physician staffing shows that group and staff HMOs have fewer primary care and specialist physicians per 100,000 enrollees than do network and mixed HMOs, which have fewer than IPAs. Larger HMOs use fewer physicians per 100,000 enrollees than smaller HMOs. Federally qualified HMOs have fewer primary care and specialist physicians per 100,000 enrollees. For-profit, nationally affiliated, and Blue Cross HMOs have more primary care and specialist physicians than do local HMOs. HMOs in areas with high per capita income have more PCPs per 100,000 and a greater proportion of PCPs in the panel. HMO penetration decreases the use of specialists, but the number of HMOs increases the use of primary care and specialist physicians in highly competitive markets. Under very competitive conditions, HMOs appear to compete by increasing access to both PCPs and specialists, with a greater emphasis on access to specialists. The review of research on HMO performance suggests that access to PCPs is better in MCOs. But access to specialists and hospitals is lower and more difficult in MCOs than FFS. Data do not suggest that processes of care, given access, are different in MCOs and FFS. MCO enrollees are more satisfied with financial aspects of a health plan and less satisfied with other aspects of health plan organization. There are potential problems with outcomes, with some studies finding greater declines among the chronically ill in MCOs than FFS. We found a variety of innovative care programs for the elderly, based on two fundamentally different approaches: organization around primary care or organizing around specialty care. Differences between the performance of the two approaches cannot be evaluated because of the small amount of research done. It is difficult to say how well particular programs perform and if they can be replicated. The innovative programs described in the literature tend to be benchmark programs developed by HMOs with a strong positive reputation.

Aged↗

PubMedDate not supplied

The practice of certified community health CNSs.

PURPOSE/OBJECTIVES: This study explored the practice of clinical nurse specialists (CNSs) certified in Community Health nursing in the United States and described demographic and employment characteristics and perspectives about professional practice. METHODS: The survey method was used. Of the 209 Community Health CNSs certified by American Nurses Credentialing Center (ANCC) invited to complete the investigator-designed mail questionnaire, 111 (53%) returned a completed questionnaire. The questionnaire contained 27 items about employment, income, years in practice, certification, career satisfaction, and educational preparation, and asked participants to indicate the fit between the Community Health CNS role and the traditional CNS subroles model described by the American Nurses Association (ANA) (The Role of the Clinical Nurse Specialist, 1986) and the updated National Association of Clinical Nurse Specialists (NACNS) CNS practice model (Statement on Clinical Nurse Specialist Practice and Education, 1998). Content validity was established by Community Health CNS reviewer feedback. ANALYSIS: Quantifiable data were tallied and analyzed using standard spreadsheet computer software. Qualitative data were summarized for content themes. FINDINGS: The majority of participants were white, middle-aged females who reported being satisfied with their careers as Community Health CNSs. Most indicated that they were respected by colleagues, that they had been adequately prepared by their education, and that their current work made good use of their education and expertise. When asked to identify, by percentage of effort, the fit between their job responsibilities and the traditional subroles model of practice, the mean of reported fit was as follows: educator, 35%; administrator/leader, 22%; clinician, 21%; consultant, 14%; and researcher, 8%. The fit between job responsibilities and the spheres of influence in the NACNS model of practice was reported to average 39% for patient/client, 35% for organization/network, and 25% for nurses/ nursing practice. CONCLUSIONS: Community Health CNS is a viable specialty practice with long-term career options. The subrole functions-described by ANA-of clinician, educator, administrator/leader, consultant, and to a lesser extent researcher apply to the role. The more intergraded updated model offered by NACNS also fits Community Health CNS practice with more emphasis on patient/client and organization/ network spheres than on nurses/nursing practice sphere. IMPLICATIONS: Schools of nursing should continue to offer the Community Health CNS programs and incorporate both the traditional functions and newer practice model into their curricula, with a greater emphasis on diversity of students to help ensure a more diverse CNS population. Further research is needed to explore the outcomes of Community Health CNS practice and the factors that contribute to role satisfaction.

Adult↗

PubMed2002

Evaluation of a mental health outreach service for homeless families.

AIMS: To describe the characteristics of homeless children and families seen by the mental health outreach service (MHOS), to evaluate the impact of this service on the short term psychosocial functioning of children and parents, and to establish perceptions of, and satisfaction with, the service. METHODS: Twenty seven children from 23 families who were in receipt of the MHOS and 27 children from 23 families residing in other hostels where no such service was available were studied. The MHOS was delivered by a clinical nurse specialist with expertise in child mental health, who offered the following interventions: assessment and brief treatment of mental health disorders in children; liaison with agencies; and training of homeless centre staff. RESULTS: Children in the experimental group had a significantly higher decrease in Strengths and Difficulties Questionnaire (SDQ) total scores. Having received the intervention was the strongest predictor of improvement in SDQ total scores. There was no significant impact on parental mental health (General Health Questionnaire) scores. Homeless families and staff expressed high satisfaction with the MHOS. CONCLUSION: This MHOS for homeless families is an innovative intervention which meets the complex and multiple needs of a vulnerable population unable to access mainstream mental health services. The primary objective of the service was to improve child mental health problems; however, the service developed in a responsive way by meeting social and practical needs of families in addition to its clinical role.

Adult↗

PubMed2001

An assessment of delays in obtaining definitive breast cancer treatment in Southern Italy.

Female population is medically underserved in Southern Italy (in comparison with other Italian regions). In a recent systematic review of published studies, delays of 3-6 months between symptom onset and treatment have been clearly associated with lower survival rates for breast cancer patients. The aim of this study was to examine breast cancer delays in medically underserved patients in Southern Italy, in order to recognize their determinating factors so as to provide women with a better opportunity for survival. The variables examined were age, education, symptom status at first presentation: symptomatic and asymptomatic, date of first symptom presentation, date of first consultation with a health provider, consulted provider, tumor size and nodal status, according to the pTNM system. Time intervals were categorized into: < 1 month, 1-3 months and > 3 months for patient and medical delay; 1-3 months, 3-6 months, > 6 months for overall delay. Patient delay was associated with education: a higher risk was found for women with < or = 5 years school attendance (OR = 3.3, 95%, CI 2.0-5.6). Medical delay was seen to be associated with the professional figure: significant differences were found between senologists (oncologist exclusively dedicated to breast cancer) and other specialists (OR 3.5, 95%, CI 1.5-8.4). Age and symptomatic presentation were found to be high risk factors. Concerning tumor size in overall delay in cases > 2 cm had OR values were of 2.4 (95%, CI 1.5-3.7). In conclusion our study suggests that diagnostic delay is associated with medically underserved status and can be reduced by educating younger and less educated women, as suggested in other studies and by providing training programs for members in the medical profession.

Adult↗

PubMed2002

Ear diseases and hearing in the Thai elderly population. part II. A one year follow-up study.

The ear and hearing survey of the Thai elderly in 14 urban communities around Siriraj Hospital was repeated one year after the first survey in order to detect any changes. Altogether 556 elderly people came for follow-up examination, 191 were males, 365 were females, the average age was 68.2 years (60-88 years). Ear disease was diagnosed by ENT specialists in 80 cases which implied that the prevalence of ear disease was 14.4 per cent. This was not statistically significantly different from the prevalence of ear disease in the survey conducted in the previous year and although the elderly who had ear diseases in the first survey had already been treated, the prevalence did not decrease. Some elderly people only had ear diseases in this survey. Hearing evaluation by pure tone audiometry was performed in 549 elders. There were 12.4 per cent who had bilateral, moderate to severe hearing loss which was 2.9 per cent higher than in the previous survey. The hearing level had also deteriorated in 14.3 per cent of the elderly people. Tympanometry was performed in 556 cases and showed that 10.5 per cent had a conductive hearing loss. When audiometry and tympanometry of the same elderly people were evaluated together, 49.2 per cent of them had a sensorineural hearing loss, 3 per cent had a conductive hearing loss and 6.5 per cent had a conductive or mixed type hearing loss. When the results of audiometry were compared with the self identification/perception of their hearing reported by the elderly in the questionnaires, they were not reliable. In conclusion, a one-year follow-up study of the prevalence of ear disease and hearing impairment in the elderly showed that the prevalence of ear disease was still high and had not changed significantly. Concerning hearing impairment, not only had the prevalence increased, but also the severity of hearing loss. Therefore, the authors stress the need to implement the "Ear and Hearing Care" program for the elderly both in rural and urban communities at least once a year in order to improve quality of life of the elderly Thai people and to prevent complications of ear disease.

Acoustic Impedance Tests↗

PubMed2006

Early intervention in developmental delay.

OBJECTIVES: To establish the socio-demographic and clinical profile of children attending Early Intervention Program (EIP). METHODS: Retrospective analysis of case records of 100 consecutive children examined from July 2002 to June 2004. Data regarding socio-demographic variables, clinical profile, locomotor, speech and audiology functions were recorded. Data is described in terms of frequency and mean (with SD). RESULTS: Mean age of these children was 4.0 +/- 1.4 years. 70% were male and a similar percentage hailed from urban areas. 88% were mentally retarded with mean IQ of 50 +/- 24.3. Cerebral Palsy was seen in 50% of the children, learning disorder in 24%, Attention Deficit Hyperactivity Disorder (ADHD) in 12% and autism in 4%. 25% of children suffered from epilepsy and 66% were unable to communicate verbally. 21% of children had strong evidence of genetic disorders. An etiological diagnosis could not be made in 31% of children. CONCLUSIONS: Awareness of developmental delay as well as of possible interventions is low in India. Speech delay is the only delay which is considered important by parents. Active involvement and early referrals from pediatricians, obstetricians and other specialists is suggested.

Child, Preschool↗

PubMedDate not supplied

Quality of care provided to patients with diabetes mellitus in Puerto Rico; managed care versus fee-for-service experience.

OBJECTIVE: To evaluate and compare the quality of diabetes care in a large managed care system and fee-for-service payment system in Puerto Rico. METHODS: This retrospective cross-sectional study assessed the adherence to standards of diabetes care in 1,687,202 subjects--226,210 from a fee-for-service population and 1,460,992 from a managed care group. Patients with diabetes mellitus were identified from insurance claims reports. Type of health-care provider, service location, number of visits, and laboratory utilization were also assessed. RESULTS: From the analysis, we identified 90,616 patients with diabetes (5.4% of the overall study group). Of these, 66,587 (73.5%) were found to have at least one encounter with a physician in a medical visit. Of the 66,586 patients with diabetes who visited a physician, only 4% were treated by an endocrinologist. General laboratory utilization was 34% for the entire population of patients with diabetes studied. In the group of patients with documented laboratory tests, 93% had a documented fasting blood glucose test; in contrast, hemoglobin A lc testing was performed in only 9% of the patients. The fee-for-service group had a higher rate of visits to medical specialists and general laboratory utilization, whereas the managed care group had a higher rate of hospital admissions and emergency department visits. CONCLUSION: The quality of diabetes management and the subsequent outcomes are related to patient and health-care provider adherence to standards of care. In this analysis, we found that patients and physicians are responsible for low compliance with recognized standards of diabetes care in Puerto Rico. The lack of adequate management will lead to increased mortality, development and severity of chronic complications, and increased emergency department utilization. Therefore, health-care providers and payers should find ways to achieve more effective promotion of adherence to accepted standards of care for patients with diabetes.

Aged↗

PubMed2004

Use of complementary and alternative medicine in Israel: 2000 vs. 1993.

BACKGROUND: Complementary and alternative medical care has gained increasing popularity in western societies in recent years. OBJECTIVES: To provide a cross-sectional and temporal (2000 vs. 1993) analysis of the use of complementary and alternative medicine in Israel. METHODS: The subjects studied represented the Israeli Jewish urban population aged 45-75 years. Full sit-down interviews were conducted with 2,003 respondents in 1993 and 2,505 respondents in 2000. RESULTS: For 1993, 6% of the population reported on consultations with CAM providers during the previous year. For 2000, that proportion increased to 10%. Being a woman, having higher education, enjoying better economic status, being younger, living in a big city, and being dissatisfied with specialists' care were all positively related to the use of non-conventional medicine, particularly in 2000. In both years, more than 50% of the consultations were with acupuncturists and homeopaths. However, chiropractors have doubled their market shares, and lower back pain became the leading problem for which care was sought. The main reason for consulting CAM was a reluctance to use too many drugs or to undergo an invasive procedure. However, a significant proportion of the users continue to use conventional medicine concurrently. Seventy-five percent in 2000 and 60% in 1993 reported that the treatment helped. CONCLUSIONS: Between 1993 and 2000, CAM in Israel changed from an infant industry into a mainstream medical commodity, reflected in both prevalence and different patterns of consumption.

Age Factors↗

PubMed2004

Consensus statement on office-based treatment of opioid dependence using buprenorphine.

Buprenorphine and buprenorphine/naloxone (BUP) are newly approved for office-based treatment of opioid dependence. Federal and non-federal regulatory and monitoring agencies, national and international researchers, national professional organizations, researchers involved in monitoring, opioid treatment programs and the pharmaceutical industry met to synthesize and disseminate practical information to guide training, practice, monitoring, regulation and evaluation efforts with these medications. We performed a review of the literature, training curricula and practice guidelines and commissioned manuscripts describing recently completed, or still in progress, studies or field experiences with BUP treatment. A consensus process generated fifteen statements: (1) The federal government should collect baseline data on opioid-related deaths and morbidity to assess the effect of BUP on public health, (2) the patient limit for group practices should apply to individual physicians rather than group practices, (3 and 4) telephone and Internet-based physician and pharmacist support is needed, (5) clinicians who provide psychosocial services to opioid dependent patients should be informed of the role of BUP, (6) opioid-dependent patients should be instructed to present for induction in mild withdrawal, (7) the existing Center for Substance Abuse Treatment guidelines provide a reasonable induction protocol, (8) physicians should be prepared to use ancillary medications with BUP induction, (9) a physician or nurse must be available to the patient during the induction period, (10) concurrent counseling and support services are necessary, (11) detoxification without appropriate followup addiction treatment leads to rapid relapse and is not as effective as maintenance, (12) pregnant opioid-dependent women should be treated using good clinical practice including specialist addiction care and prenatal care, (13) BUP induction and withdrawal treatment may benefit from different designations for payment, (14) take-home medication options should be tailored to patients' needs, (15) there is a need for clinical and policy research in unique patient populations.

Ambulatory Care↗

PubMed2003

What do physician recommendations of health plans mean?

OBJECTIVE: To examine what determines physician recommendations of health plans and whether their recommendations reflect experiences with specific plans. STUDY DESIGN: Cross-sectional mail and telephone survey. PARTICIPANTS AND METHODS: A sample of 11453 physicians was surveyed from November 2000 to early 2001, and 3798 (2105 generalists, 1693 specialists) responded. After adjusting for ineligibles and duplicates, the response rate was estimated to be between 41% and 45%. Physician respondents were from 23 health plans in 5 regions: Florida, New York, Colorado, Pennsylvania, and Washington. Plans included those serving commercial, Medicare and Medicaid populations and represented group/staff type HMOs, independent practice associations, and preferred provider organizations. Measurements included self-reported experience with 9 health plan care management strategies and ratings of managed care beliefs and satisfaction with pay. Physicians were asked about their willingness to recommend the health plan to a family member or friend, to people with serious illnesses, or to other physicians. RESULTS: Physician recommendations of a health plan were associated with the health plan's care management activities and with the physician's generalized beliefs about managed care and satisfaction with pay. CONCLUSION: Physician health plan recommendations can reasonably be interpreted as partially reflecting physician experiences with specific plans. Therefore, they can play a role in helping purchasers and consumers compare health plans.

Adult↗

PubMed2006

Oral health care in Canada--a view from the trenches.

PURPOSE: Concern is increasing over the effect of lack of access to oral health care on the oral health, and hence general health, of disadvantaged groups. In preparation for a national symposium on this issue, key informants across Canada were canvassed for their perceptions of oral health services and their recommendations for improving oral health care delivery. This paper reports the results of that survey. METHOD: A questionnaire was constructed to address problems facing agencies with responsibility for meeting the oral health care needs of people receiving government assistance, the underhoused and the working poor. The survey was sent to 200 agencies, government and professional organizations. Data from the returned questionnaires were entered into a Statistical Package for the Social Sciences database and analyzed. Responses from Ontario were compared with those from the rest of Canada, those from government organizations were compared with others and results were examined by cultural nature of clients and by type of organization. RESULTS: In assessing the positive aspects of oral health care, 84% of respondents agreed that public programs were useful and 81% felt that dentists offer good care. However, 77% disagreed that preventive care is accessible and that access to dentists and dental specialists is easy. More Ontarians than others thought that there are few alternative settings for care delivery (95% vs. 83%) and that the poor feel unwelcome in dental offices (83% vs. 70%). The issues most commonly identified were the need for alternative delivery sites, such as community health centres where service delivery could be affordable, accountable and sustainable; the need for oral health to be recognized as part of general health; regulatory issues (e.g., expanding practice opportunities for non-dentist oral health care providers and removing restrictions on other dental health professionals in providing basic care to the financially challenged); and training. DISCUSSION: The survey helped to identify access and care issues across the country. There was considerable agreement that lack of access to dental care services is an important detriment to the oral and general health of many Canadians. Respondents believe that dental health is isolated from general health.

Canada↗

PubMed2001

Health protocol for translocation of free-ranging elk.

When considering an elk (Cervus elaphus) restoration program, wildlife managers must evaluate the positive and negative elements of translocation. We prepared this protocol to give an overview of health considerations associated with translocation of elk, with an emphasis on movement of free-ranging elk from western North America to the southeastern USA. We evaluated infectious agents and ectoparasites reported in elk from two perspectives. First, we made a qualitative estimate of the ability of the agent to be introduced and to become established. This was done using a selected set of epidemiologic factors. Second, if there was a good possibility that the organism could become established in the release area, the potential pathological consequences for elk and other wildlife, domestic animals, and humans were assessed via examination of the literature and consultation with other animal health specialists. The results of these evaluations were used to classify infectious agents and ectoparasites as low risk (n = 174), unknown risk (n = 10), and high risk (n = 9). We classified Anaplasma marginale, Anaplasma ovis, Mycobacterium paratuberculosis, Pasteurella multocida serotype 3, Elaphostrongylus cervi, Dicrocoelium dendriticum, Fascioloides magna, Echinococcus granulosus, Dermacentor albipictus, and Otobius megnini as unknown risks. High risk infectious agents and ectoparasites were the agent of chronic wasting disease, Brucella abortus, Mycobacterium bovis, Dermacentor andersoni, Ixodes pacificus, and Psoroptes sp. Parelaphostrongylus tennis, Elaeophora schneideri, and a Babesia sp. are parasites endemic in the southeastern USA that may present a "reverse risk" and adversely affect elk if released in some parts of the region. We developed a five-component protocol to reduce the risk of introduction of high risk infectious agents and ectoparasites that included: (1) evaluation of the health status of source populations, (2) quarantines, (3) physical examination and diagnostic testing, (4) restrictions on translocation of animals from certain geographic areas or populations, and (5) prophylactic treatment.

Animal Welfare↗

PubMed2004

Health care in the circumpolar world: Greenland.

Greenland is part of the Kingdom of Denmark and it is the world's largest island. An ice cap covers 85% of its territory. The population is about 57,000 inhabitants, with 14,000 living in the capital Nuuk, and 10,000 in villages and other small settlements. There are pronounced regional variations in lifestyle and living conditions. The Greenland Home Rule Government assumed responsibility, for health care on 1 January 1992. Greenland's territory is divided into 16 health care districts. Queen Ingrid's Hospital in Nuuk is the national hospital and has 156 beds and numerous specialist physicians associated with it. Each health district has a health care centre with one or more physicians, nurses and other health care personnel appropriate for the number of people living in the district. Each district health centre is responsible for primary health care in towns, villages and other small settlements, and the health centres treat all common illnesses. The health centres handle uncomplicated births, minor surgery, common treatment in internal medicine and community mental health services. The centres have a number of inpatient beds proportional to the number of people in the health district. People with more complicated illnesses are referred to Queen Ingrid's Hospital in Nuuk or to specialised treatment in Denmark.

Delivery of Health Care↗

PubMed1997

How can vascular surgery survive capitated care?

The basic differences between fee-for-service and capitated care are characterized and how they are likely to impact the practicing vascular surgeon are explored. Likely practice scenarios under capitated care are given. If the potential problems associated with using primary care "gate keeper" physicians materialize, secondary "carveouts" by vascular specialists may prove feasible. The alternative, particularly in large patient care consortiums, is to educate gatekeepers with efficient management algorythms in exchange for appropriate referrals. In spite of demonstrable flaws and abuses, capitated, managed care is likely to persist in some form, as an effective way to control spiraling health care costs. Therefore, vascular surgeons need to be prepared to compete under such systems. The major keys to success are efficient use of diagnostic tests, applying conservative, cost conscious indications for intervention, and efficient use of hospital resources (judged by lengths of stay in the intensive care unit and hospital and readmissions under the same diagnosis). In addition to developing better practice profiles, in these and standard mortality and morbity parameters, vascular surgeons need to create or join an efficient practice environment, with a minimum number of efficient personnel and teaching and research costs tightly controlled. To negotiate contracts effectively, vascular surgeons must know their costs, of delivering care on a per capita basis in their environment, adjusted for specific (eg, working or retired) patient populations. Outcomes and cost comparisons and other management research must vie for attention with new technology and basic research.

Capitation Fee↗

PubMed2002

A continuing educational initiative to develop nurses' mental health knowledge and skills in rural and remote areas.

At a time of ever increasing mental health problems in Australian society, the nursing profession is beset by problems of an insufficient workforce specialising in this area. Not only is there a shortage of suitable trained specialist mental health nurses, but undergraduate nursing programs inadequately prepare students for practical mental health nursing. Fewer students are enrolling in mental health nursing, and many nurses are leaving the workforce. A particular problem in rural Australia is that there is a lack of specialist mental health services, and nurses are being increasingly relied upon to perform the role of mental health nurse despite lacking the necessary qualifications and experience.This paper aims to describe the development, implementation and evaluation of a mental health continuing education program for nurses employed in rural and remote areas of New South Wales (NSW), Australia. This was a collaborative educational initiative mounted by the NSW Health Department (who funded the project), a rural university and a number of regional health service partners. The paper includes information on how this program was conceived, developed and conducted through distance education mode. It also evaluates the efficacy of this program as perceived by 202 out of 303 participants. Overall the project was rated very favourably, and represents a cost-effective, convenient method of enabling rural and regional nurses to update and improve their skills in mental health nursing.

Adult↗

PubMed2006

Integrated psychiatric/medical care in a chronic hepatitis C clinic: effect on antiviral treatment evaluation and outcomes.

OBJECTIVES: Psychiatric and substance use disorders are common in hepatitis C patients and represent barriers to antiviral treatment. We evaluated the effect of integrating psychiatric and medical care on evaluation for and initiation of antiviral treatment in a cohort of 184 patients with chronic hepatitis C. METHODS: Integrated care consisted of screening for psychiatric problems with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), Beck Depression Inventory (BDI), Urine Drug Screen (UDS), and Primary Care Posttraumatic Stress Disorder (PC-PTSD) screens, referral based on specified cutoff scores to an established mental health (MH) provider, to a colocated psychiatric clinical nurse specialist (PCNS), or both. Data were collected retrospectively by chart review. RESULTS: Most patients (149/184, 81.0%) had at least one positive screen, 25.5% had a positive UDS. Among patients with positive screens, 38.3% had established MH providers, 47.0% had no MH provider and were referred to the PCNS, and 15.0% refused any psychiatric referral. Patients receiving integrated care with a colocated PCNS were significantly more likely to complete evaluation for and start antiviral treatment than other patients with positive screens, and at a rate similar to that of patients with negative screens. Patients with positive screens followed by any MH provider had significantly greater adherence to antiviral therapy than patients without positive screens. CONCLUSION: An integrated MH and medical approach was associated with rates of antiviral therapy recommendation and initiation similar to patients without risks for psychiatric or substance use problems. MH care was associated with improved adherence to antiviral therapy. Integrated care offers promise as an approach for addressing psychiatric comorbidity in this traditionally difficult to treat population.

Antipsychotic Agents↗

PubMed1998

Airborne surgical outreach services in eastern Africa.

BACKGROUND: African Medical and Research Foundation (AMREF) has for forty years offered airborne specialist surgeons or surgical teams to supplement the major surgery conducted by local hospital staff, particularly in Kenya and Tanzania. OBJECTIVE: To quantify and qualitatively describe the contribution of airborne surgical outreach services in relation to the total surgical output of remote rural hospitals in Kenya and Tanzania. DATA SOURCES: Surgical theatre registration books of one government and two church/mission owned hospitals in Kenya and Tanzania from 1994 to 1995; and service records kept by the surgeons during outreach trips in the same period. RESULTS: AMREF contributed 15.1% of all major operations, and operations performed by AMREF were relatively complex. The average number of AMREF's major operations performed per visit was 17 and per visit day 4.3. Numerous minor operations and examinations, ward rounds and an average of 10 patient consultations per day were done during the visits. CONCLUSIONS: Total population-based operation rates, and rates by sex and age, are useful indicators for monitoring and comparison. Every hospital should report, annually, major operations performed by type and by age and sex of patients, with special mention of operations and consultations performed by visiting teams, if any. Each hospital should also state the estimated population of its current catchment area.

Aviation↗