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PubMed1998

Satisfaction with dental care among elderly Finnish men.

To study satisfaction with dental care among elderly Finnish men and to estimate the role of different factors affecting it, a questionnaire was sent to a systematic sample of 2043 elderly Finnish men (mean age 73 years). Acceptably filled-out questionnaires were returned by 1561, a participation rate of 76.4%. The questionnaire included 44 questions concerning dental and denture services and a modified 14-item Dental Satisfaction Questionnaire. The subjects were asked to express how strongly they agreed or disagreed with each of the 14 statements. These were later transformed and recoded to indicate level of satisfaction from +2 (very satisfied) to -2 (very dissatisfied). Overall satisfaction was estimated by summing up all the 14 scores. Dentate subjects were significantly (P<0.01) more satisfied than the edentulous. Subjects were least satisfied with dental care fees and most satisfied with accessibility and availability of services. Dentate subjects viewed almost all 14 items significantly more favorably than did the edentulous. Economics was seen to have a strong influence on dissatisfaction with dental care fees, which was related to income level. Maintaining the remaining dentition and supporting the dentition with fixed or removable dentures seem to be the means to increase satisfaction among the dentate. The benefits of belonging to a clinic's recall system should be explained thoroughly to the elderly.

Age Factors↗

PubMedDate not supplied

The effect of an alphanumeric paging system on patient compliance with medicinal regimens.

There are numerous actual and potential impediments to patient compliance with medicinal regimens. The implications of poor compliance include worsening disease states or symptoms, with resultant increased costs of care. Using a population of hospice patients at high risk for noncompliance, this study evaluated the use of an alphanumeric paging system as a memory prosthetic, finding that compliance rose from a mean of 56 percent to 96 percent when the system was used. We conclude that such a program is of use in this setting, and that these findings warrant study and suggest applications in other populations.

Aged↗

PubMed2000

Cost-effectiveness of childhood immunization reminder/recall systems in urban private practices.

OBJECTIVE: To assess cost and cost-effectiveness of immunization reminder/recall systems in the private sector. METHODS: A manual postcard system (mail) was compared with a computer-based telephone system (autodialer) and control. Costs included time costs and the cost of equipment and supplies. The cost per child and the incremental cost of the intervention relative to control were computed. Cost-effectiveness ratios were computed for return visits and for immunizations delivered. RESULTS: The average cost per child was $2.28 for the mail group and $1.47 for the autodialer group. The incremental visit cost relative to the control was higher for the mail group ($9.52) than for the autodialer group ($3.48). The autodialer was more cost-effective in delivering immunizations: $4. 06 per extra immunization (autodialer) versus $12.82 (mail). CONCLUSIONS: Excluding start-up costs, the autodialer system was most cost-effective. Including autodialer equipment costs, the autodialer system is more cost-effective only for larger practices.

Cost-Benefit Analysis↗

PubMed1997

The effect of the family physician on improving follow-up after an abnormal PAP smear.

OBJECTIVE: The aim of this study was to assess the effect of the family physician on improving compliance with follow-up of abnormal smears in cervical cancer screening. DESIGN: Observational study. SETTING: Two Regional Health Authority districts in the east of The Netherlands. STUDY PARTICIPANTS: Family practices with a national call system for cervical cancer screening and family practices with a family-practice-based call system. In a number of practices the family physicians had introduced a fail-safe system for follow-up. MAIN OUTCOME MEASURES: Follow-up of women who participated in the first screening round and in whom a cytological abnormality had been diagnosed in the first smear. Criteria for adequate follow-up were defined with regard to the severity of the cytological abnormality. RESULTS: The overall compliance with follow-up in the study-group was 88%. The study showed a strong relationship between involvement of the family physician and compliance with follow-up. The compliance in practices that had a fail-safe system for follow-up was 93% compared to 82% in the practices without a fail-safe system. The highest follow-up was found in practices involved in the family-practice-based system.

Adult↗

PubMed2001

Direct observation of counseling on colorectal cancer in rural primary care practices.

To better understand colorectal cancer (CRC) screening practices in primary care, medical students directly observed physician-patient encounters in 38 physician offices. CRC was discussed with 14% of patients >or=50 years of age; 87% of discussions were initiated by the physician. The rate of discussions varied among the practices from 0% to 41% of office visits. Discussions were more common for new patient visits, with younger patients, and in the 24% of offices that utilized flow sheets. The frequency of CRC discussions in physician offices varies widely. More widespread implementation of simple office systems, such as flow sheets, is needed to improve CRC screening rates.

Colorectal Neoplasms↗

PubMedDate not supplied

The use of automated prompting to facilitate handwashing in persons with dementia.

As the number of people living with dementia increases, occupational therapists are challenged with finding innovative, evidence-based ways to enable daily occupations. The use of computer technology is explored in this study as one potential intervention for this population. An automated prompting system was modified to provide both verbal and audiovisual prompts, and 8 participants with Standardized Mini-Mental State Examination (SMMSE) scores as low as 3/30 were followed over 60 trials to determine which prompting method was more effective in reducing caregiver interactions. Overall, the participants were able to complete more steps with the assistance of either automated prompt and required fewer caregiver interactions. Audiovisual prompting significantly reduced the number of caregiver interactions required. These results lend further support to the use of an automated prompting system but suggest that there are individual factors influencing the efficacy of the prompting mode, for which occupational therapists are well suited to assess and monitor.

Aged↗

PubMed1995

Prompting for cost-effective test ordering: a randomized controlled trial.

This randomized, controlled trial tests the efficacy of a computerized prompting system for test ordering. The system, makes use of the sensitivity, specificity, positive and negative predictive values of tests. It was tested using clinical vignettes in an academic family medicine center with first and second year residents. We found that there was a 38% decrease in the numbers of tests ordered (p < .01) and a 12% decrease in the costs of tests ordered by using the prompting system. We suggest that when used at the point of the patient encounter, this system has the potential for promoting more appropriate test ordering and for saving considerable health care dollars.

Clinical Laboratory Techniques↗

PubMed2004

Evaluation of an automated test ordering and feedback system for general practitioners in daily practice.

OBJECTIVE: To evaluate the use of an automated test ordering and feedback system (named GRIF) in daily practice. The system produces recommendations to general practitioners (GPs) to improve the application of accepted practice guidelines for test ordering. METHODS: A randomised controlled trial with balanced block design was carried out in general practices in two regions of the Netherlands from August 2000 to July 2001. We implemented the GRIF system on the workstations at the offices of the participating GPs. The GPs (n=11) were asked to use GRIF during patient consultation instead of filling in the paper request form. The system displayed critical comments about their non-adherence to the guidelines as apparent from the request forms. RESULTS: The median time of producing the comments plus the response time of the GP was 13s. Of the 2780 presented recommendations, 4.3% were accepted. Advice of the GRIF system that presents a concrete test to request in a particular situation is adhered to most frequently. Finally, there seems to be a decrease of accepted comments over the trial period. CONCLUSION: Computerised recommendations should contain, if possible, suggestions for alternative tests to improve the application of these recommendations. Furthermore, creative solutions must be developed to avoid that GPs get used to the recommendations of critiquing systems and to stimulate a better adherence to these recommendations.

Adult↗

PubMedDate not supplied

Inadequate follow-up of abnormal mammograms.

Routine mammographic screening increases detection of nonpalpable breast cancer. Timely follow-up of abnormalities is essential because delays may lead to postponement of treatment and decreased survival for women who have cancer. The purpose of this study was to determine the percentage of women with an abnormal mammogram who do not have adequate follow-up and to determine factors associated with inadequate follow-up. The study was conducted in a metropolitan health system that includes a large urban teaching hospital in Detroit and 26 ambulatory care centers. From the radiology database, all women with an abnormal screening mammogram performed between January 1, 1992, and July 31, 1992 were identified. We defined adequate follow-up as follow-up within three months of due date. Follow-up status was determined using medical records and telephone interviews. The percentage of women with inadequate follow-up was calculated. Relative risks compared percentages of women with inadequate follow-up according to demographic and screening-related variables. We calculated adjusted relative risks using multivariate binomial regression. We identified 1,249 women with abnormal screening mammograms. Inadequate follow-up occurred for 226 (18.1%) of the women. Among women with follow-up recommended in 4-6 months, 36.8% had inadequate follow-up. Among women with immediate follow-up recommended (obtain additional views or outside films for comparison, ultrasound, biopsy, or surgical referral), 7.2% had inadequate follow-up. Inadequate follow-up was associated with lower estimated household income and no history of previous mammogram. Among women with inadequate follow-up who were interviewed, 87% reported that they had been notified of their results. We found that the percentage of women with inadequate follow-up of abnormal mammograms is high, especially among women who require six-month follow-up. Women with low income and no history of a previous mammogram were at greatest risk for inadequate follow-up. These results document a previously unrecognized problem with mammography screening and suggest that the implementation of tracking systems to ensure timely follow-up of abnormal screening mammograms is essential. Medical Subject Headings (MeSH): mammography, follow-up, screening.

Adult↗

PubMed2001

Interinstitutional variation in glycohemoglobin monitoring and glycemic control of diabetic patients.

OBJECTIVES: To compare how frequently institutions monitor glycohemoglobin in diabetic patients, the level of glycemic control achieved and to identify institutional factors associated with higher rates of monitoring and lower glycohemoglobin levels. METHODS: A total of 212 institutions retrospectively abstracted laboratory and outpatient records of up to 30 diabetic patients who had initial glycohemoglobin monitoring performed in their laboratories. Data from a cohort of 5586 diabetic patients and 17 365 assays were analyzed. RESULTS: Overall, 31.3% of patients underwent glycohemoglobin monitoring at least quarterly, the frequency recommended by the American Diabetes Association (ADA) to stabilize patients at target hemoglobin A(1c) (HbA(1c)) levels. A total of 64.9% of patients were monitored at least semiannually, the ADA recommendation for patients with stable diabetes in glycemic control (final HbA(1c) level <7%). When we compared the top and bottom deciles of the 212 institutions, there was more than an eightfold difference in the proportion of patients monitored at least quarterly and more than a twofold difference in the proportion of patients monitored at least semiannually. Glycemic control was assessed by examining the value of the last glycohemoglobin determination on record after at least 8 months of management. For all 5586 diabetic patients, the median value of the last HbA(1c) assay was 7.4%. Comparing the top and bottom deciles, there was almost a fourfold difference among institutions in the proportion of diabetic patients in glycemic control. The use of reminders to order glycohemoglobin monitoring was associated with higher rates of semiannual monitoring (P <.05) and tighter glycemic control (P <.05). In addition, patients who were monitored more frequently experienced glycohemoglobin reductions of greater magnitude (P <.001). The presence of diabetes clinics and the use of rapid methods for testing glycohemoglobin were not associated with monitoring frequency or glycohemoglobin levels. CONCLUSIONS: There is wide interinstitutional variation in the frequency with which diabetic patients are monitored and the level of glycemic control achieved. The use of prompting systems to remind providers to order glycohemoglobin monitoring was associated with more frequent monitoring and superior glycemic control.

Blood Glucose↗

PubMed2001

Improving diabetes care in the primary healthcare setting: a randomised cluster trial in remote Indigenous communities.

OBJECTIVE: To evaluate a system for improving diabetes care in remote Indigenous communities. DESIGN: Randomised, unblinded cluster trial over one year (1 March to 29 February 2000). PARTICIPANTS AND SETTING: Primary healthcare staff in 21 primary healthcare centres in the Torres Strait and Northern Peninsula Area (NPA) Health Service District, north Queensland, and 678 people with diabetes, mostly Torres Strait Islanders. INTERVENTION: Diabetes recall system established at eight of the 21 sites, as well as staff training in basic diabetes care, regular phone calls from the project officer, a two-monthly newsletter and a mid-project workshop. MAIN OUTCOME MEASURES: Regular checks of weight, blood pressure, eye and foot care, serum lipid levels and glucose monitoring and control, urinary albumin to creatinine ratio and serum creatinine levels, and administration of recommended vaccines; hospitalisation in the previous 12 months. RESULTS: There was improvement in most measures at most sites, except for blood pressure monitoring and control, and vaccination status. Intervention sites showed greater improvement in most indicators than control sites (combined relative risk [RR], 1.21; 95% CI, 1.03-1.43). The intervention group showed a 32% reduction in hospital admissions for diabetes-related conditions over the study period (P=0.012). At follow-up, patients in intervention sites were 40% less likely to be hospitalised for a diabetes-related condition than those in control sites (RR, 0.60; 95% CI, 0.41-0.86; P=0.007). CONCLUSION: A simple recall system, managed by local healthcare workers and supported by a diabetes outreach service, achieved significant improvements in diabetes care and reduced hospitalisations in a high-risk population.

Diabetes Mellitus↗

PubMed1998

Diagnosis and follow-up of Chlamydia trachomatis infections in the ED.

The purpose of this study was to determine the impact on patient care and the cost effectiveness of testing for chlamydial infection in the emergency department. All patients tested for chlamydial infection in three emergency departments between October 1, 1993 and January 31, 1994 were retrospectively reviewed for charges and adequacy of therapy. In one hospital, the effectiveness of a call-back system to enhance proper therapy of inadequately treated patients was evaluated. Of 2,416 test results, 249 were positive, and 197 of these charts were available for review. All 16 male patients were treated appropriately at the initial visit; 105 of 181 female patients were inadequately treated at the initial visit. The charge to identify each patient inadequately treated was $981.22 ($103,000 for 105). Of the 28 inadequately treated patients receiving a follow-up call, 20 sought treatment. The high cost of testing patients cannot be justified without an adequate surveillance system to enhance proper follow-up treatment.

Abdominal Pain↗

PubMedDate not supplied

Self-management of instruction cues for occupation: review of studies with people with severe and profound developmental disabilities.

Helping people with severe and profound developmental disabilities acquire and maintain constructive occupation is an objective of great practical importance. During the last 15-20 years, studies directed at this goal have largely relied on five strategies of self-management of instruction cues. Those strategies consist of the use of (1) picture cues presented on sets of cards, (2) picture cues stored in computer-aided systems, (3) object cues attached to cards, (4) verbal cues stored in audio recording devices, and (5) self-verbalizations. This paper reviews the aforementioned strategies and discusses their overall effectiveness and their suitability (practicality). The paper also points out some relevant issues for future research.

Behavior Therapy↗

PubMed1999

Clothing exchanges for Medicaid members boost immunizations, encourage well-child visits.

Want your Medicaid members to get their vaccinations and well-child visits? Try encouraging them with an incentive system that offers something they can use, like children's clothing. Arizona Physicians IPA Inc., a Phoenix-based Medicaid managed care organization, uses clothing exchanges to encourage preventive utilization and give members access to community outreach programs.

Arizona↗

PubMed2006

Lessons learned from developing a tailored print intervention: a guide for practitioners and researchers new to tailoring.

Although some "how-to" guides have been written on tailored messaging, we found no reports on lessons learned from the process of developing a tailored intervention. Such lessons may be useful for practitioners and researchers who are new to tailored intervention development. The authors describe lessons gleaned from the process of developing a repeat mammography tailored print intervention. Lessons learned include the following: Selection of determinants appropriate for tailoring should be based on a theoretic framework and refined through assessment of the target population; researchers should anticipate threats to fidelity of intervention delivery because of incomplete or illogical survey data; fingerprinting enables assessment of intervention dose and how it relates to effectiveness of the tailored intervention; and a systematic process for conducting a systems test is needed to check for inconsistencies and errors before final tailored letter production. These lessons are discussed in the context of challenges and possible solutions for tailored health communication.

Female↗

PubMed2006

Error reduction in surgical pathology.

CONTEXT: Because of its complex nature, surgical pathology practice is inherently error prone. Currently, there is pressure to reduce errors in medicine, including pathology. OBJECTIVE: To review factors that contribute to errors and to discuss error-reduction strategies. DESIGN: Literature review. RESULTS: Multiple factors contribute to errors in medicine, including variable input, complexity, inconsistency, tight coupling, human intervention, time constraints, and a hierarchical culture. Strategies that may reduce errors include reducing reliance on memory, improving information access, error-proofing processes, decreasing reliance on vigilance, standardizing tasks and language, reducing the number of handoffs, simplifying processes, adjusting work schedules and environment, providing adequate training, and placing the correct people in the correct jobs. CONCLUSIONS: Surgical pathology is a complex system with ample opportunity for error. Significant error reduction is unlikely to occur without a sustained comprehensive program of quality control and quality assurance. Incremental adoption of information technology and automation along with improved training in patient safety and quality management can help reduce errors.

Diagnostic Errors↗

PubMed2004

Factors influencing the uptake of childhood immunisation in rural areas.

BACKGROUND: Childhood vaccination has been vigorously debated in recent years. Professional and parental confidence in the measles, mumps and rubella (MMR) vaccine in particular has been shaken, as reflected by its decreased uptake. AIM: To investigate the influence of practice type and the method of vaccination call/recall on childhood immunisation coverage. DESIGN: Analysis of childhood immunisation uptake rates. SETTING: General practices in the Highland NHS Health Board area in Scotland. METHOD: Data on the immunisation uptake of individual practices in the region were obtained from the Information and Statistics Division of NHS Scotland. RESULTS: Uptake of all vaccines in children reaching the age of 2 years was lower in practices using their own call/recall system than those engaged with the national system. Inducement practices achieved lower uptake than non-inducement practices for every immunisation studied, with the differences ranging from 4.7% to 7.8%. Compared with group practices, uptake of all vaccines was less for single-handed practices, with the differences ranging from 2.4% to 11.4%. A logistic regression analysis found that high uptake of the diphtheria and meningococcus group C vaccines by the age of 24 months was significantly associated with use of the national call/recall system. Only inducement practice status was significantly associated with reduced uptake in children aged 12 months. CONCLUSIONS: Engagement with the national call/recall system was associated with higher immunisation coverage for children reaching the age of 2 years. Inducement status was associated with low uptake of vaccinations in children reaching the age of 1 year.

Family Practice↗

PubMedDate not supplied

Evidence-based nursing care for patients with heart failure.

There is a gap between the evidence that supports treatments used in heart failure and day-to-day patient care. Clinical practice guidelines are evidence-based and suggest best practices; however, healthcare providers, patient and system factors complicate the diagnosis and must be addressed. Performance measures specific to nursing can be derived from the guidelines to guide practice and increase high-quality care. Innovative practice improvement programs, clinical leaders, and system tools are needed to close the gap. Nurses can facilitate processes that advance care planning and promote effective care delivery as part of a multidisciplinary team of healthcare providers.

Advance Care Planning↗