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PubMed2004

Validation of a multistage asthma case-detection procedure for elementary school children.

OBJECTIVE: The purpose of this study was to validate a 3-stage asthma case-detection procedure for elementary school-aged children. METHODS: The study was performed in 10 elementary schools in 4 inner-city school systems, with a total enrollment of 3539 children. Results of the case-detection procedure were compared with the diagnosis of an asthma specialist study physician, to determine the sensitivity and specificity of the case-detection procedure. RESULTS: Ninety-eight percent of children returned the asthma symptoms questionnaires, and 79% of those children consented to additional testing. Results indicated that the 3-stage procedure had good validity, with sensitivity, specificity, and predictive value of 82%, 93%, and 93%, respectively. A 2-stage procedure using questionnaires and spirometry had similar validity, with sensitivity, specificity, and predictive value of 78%, 93%, and 93%, respectively. However, given the time and expense associated with the 2- or 3-stage procedure and the difficulty of obtaining physician follow-up evaluation of the case-detection diagnosis, schools may prefer to use a 2-item questionnaire that has a lower sensitivity (66%) but higher specificity (96%) and predictive value (95%). CONCLUSIONS: Case-detection programs are generally well received by school personnel and can identify children with unrecognized or undiagnosed disease, as well as those with a current diagnosis but poorly controlled disease. This study yields substantial information regarding the validity, yield, and specific types of children who might be identified with the use of such procedures. For the choice of the method of case detection used in a school, the strengths and weaknesses of each procedure, as well as the resources available for case detection, physician referral, and follow-up procedures, must be considered.

Asthma↗

PubMed2002

Grown-up congenital heart (GUCH) disease: current needs and provision of service for adolescents and adults with congenital heart disease in the UK.

This report addresses the needs and problems of grown-up congenital heart (GUCH) patients and makes recommendations on organisation of national medical care, training of specialists, and education of the profession. The size of the national population of patients with grown-up congenital heart disease (GUCH) is uncertain, but since 80-85% of patients born with congenital heart disease now survive to adulthood (age 16 years), an annual increase of 2500 can be anticipated according to birth rate. Organisation of medical care is haphazard with only three of 18 cardiac surgical centres operating on over 30 cases per annum and only two established specialised units fully equipped and staffed. Not all grown-ups with congenital heart disease require the same level of expertise; 20-25% are complex, rare, etc, and require life long expert supervision and/or intervention; a further 35-40% require access to expert consultation. The rest, about 40%, have simple or cured diseases and need little or no specialist expertise. The size of the population needing expertise is small in comparison to coronary and hypertensive disease, aging, and increasing in complexity. It requires expert cardiac surgery and specialised medical cardiology, intensive care, electrophysiology, imaging and interventions, "at risk" pregnancy services, connection to transplant services familiar with their basic problem, clinical nurse specialist advisors, and trained nurses. An integrated national service is described with 4-6 specialist units established within adult cardiology, ideally in relation or proximity to university hospital/departments in appropriate geographic location, based in association with established paediatric cardiac surgical centres with designated inpatient and outpatient facilities for grown-up patients with congenital heart disease. Specialist units should accept responsibility for educating the profession, training the specialists, cooperative research, receiving patients "out of region", sharing particular skills between each other, and they must liaise with other services and trusts in the health service, particularly specified outpatient clinics in district and regional centres. Not every regional cardiac centre requires a full GUCH specialised service since there are too few patients. Complex patients need to be concentrated for expertise, experience, and optimal management. Transition of care from paediatric to adult supervision should be routine, around age 16 years, flexibly managed, smooth, and explained to patient and family. Each patient should be entered into a local database and a national registry needs to be established. The Department of Health should accept responsibility of dissemination of information on special needs of such patients. The GUCH Patients' Association is active in helping with lifestyle and social problems. Easy access to specialised care for those with complex heart disease is crucial if the nation accepts, as it should, continued medical responsibility to provide optimal medical care for GUCH patients.

Adolescent↗

PubMed2003

Renal transplantation at Oregon Health and Science University: recent results and protocols.

Renal transplants have been performed at the University Hospital, Portland, OR since 1959. In the 5-year period between January 1997 and December 2001, 736 kidney-only transplants were performed at our institution. Living donor transplants comprise an increasing proportion of the transplants performed. Our patient and graft survival rates, both short- and long-term reflect the close collaboration between the transplantation medicine and transplantation surgery faculties, and the excellent support from nurse-coordinators, histocompatibility laboratory specialists and the organ procurement organization. Since September 2001, we have used a risk-based immunosuppression algorithm. The incidence of acute rejection within the first 3 months following transplantation ranged from 7-18% in the different risk groups. We have incorporated surveillance renal allograft biopsies into our standard of care and biopsies are performed at 3 months and one year after transplantation. The incidence of subclinical rejection was 15% on the 3-month surveillance biopsies and 4% on the one-year biopsies. The majority of these rejection episodes were CCTT type I acute rejection, which responded to treatment with pulse steroids. Since 1991, we have been transplanting kidneys from blood group A2 donors into blood group B or O recipients. Graft survival is similar to that in patients receiving an ABO compatible transplant. We have recently adopted the use of intravenous immune globulin to abrogate a positive crossmatch and allow transplantation of a kidney from a living donor. Six patients have been successfully transplanted using this protocol. In an effort to speed up the work-up of recipients waiting for a deceased donor kidney transplant, we have implemented a computer-driven algorithm. By generating a list of patients who should be crossmatched, and by automating generation of work sheets and reports, this computer-driven program has expedited deceased donor workups.

ABO Blood-Group System↗

PubMed2004

Survey of specialized tertiary care facilities for adults with congenital heart disease.

BACKGROUND: Specialized tertiary care facilities developed in response to the increasing numbers of adults with congenital heart disease (CHD). Because this patient population comprises a relatively new area of specialized cardiovascular interest, the first facilities necessarily evolved without preexisting guidelines or interaction. OBJECTIVES: To characterize the major features of the six original and largest tertiary adults CHD facilities. METHODS: Written questionnaire sent to six participating facilities in North America and Europe. Information was analyzed centrally. RESULTS: All but one facilities was established over 20 years ago, and each cares for over 1500 patients. Hospital admissions ranged from 100 to 660 patients/unit/year. Of the total number of registered patients, 52-81% had undergone one or more reparative surgeries. Reoperations constituted 25-80% of the 50-170 operations/unit/year. Overall mean surgical mortality was 1.9%/year. Inpatient and outpatient care was provided in adult (n = 4) or both adult and pediatric (n = 2) settings. All six facilities enjoyed close collaboration between adult and pediatric cardiologists, cardiac surgeons, nurse specialists and cardiac and non-cardiac consultants. Training and research were pivotal activities. CONCLUSIONS: Provision of comprehensive care by multidisciplinary teams including adult and pediatric cardiologists, cardiac surgeons, specialized nurses and other cardiac and non-cardiac consultants was the unifying feature for all six tertiary care facilities reported here. There were minor differences among them based on available resources, local expertise and national health care policies. There appears to be a significant shortfall in tertiary care provision for the adult with CHD that requires further planning and resource allocation. These data may be useful for new and evolving adult CHD services.

Adolescent↗

PubMedDate not supplied

Downsizing the physician workforce.

OBJECTIVE: To estimate the need for downsizing the physician workforce in a changing health care environment. METHODS: First assuming that 1993 physician-to-population ratios would be maintained, the authors derived downsizing estimates by determining the annual growth in the supply of specialists necessary to maintain these ratios (sum of losses from death and retirement plus increase necessary to parallel population growth) and compared them with an estimate of the number of new physicians being produced (average annual number of board certificates issued between 1990 and 1994). Then, assuming that workforce needs would change in a system increasingly dominated by managed care, the authors estimated specialty-specific downsizing needs for a managed care dominated environment using data from several sources. RESULTS: To maintain the 1993 199.6 active physicians per 100,000 population ratio, 14,644 new physicians would be needed each year. Given that an average of 20,655 physicians were certified each year between 1990 and 1994, at least 6011 fewer new physicians were needed annually to maintain 1993 levels. To maintain the 132.2 ratio of active non-primary care physicians per 100,000 population, the system needed to produce 9698 non-primary care physicians per year, because an average of 14,527 new non-primary care physicians entered the workforce between 1990 and 1994, downsizing by 4829, or 33%, was needed. To maintain the 66.8 active primary care physicians per 100,000 population ratio, 4946 new primary care physicians were needed per year, since primary care averaged 6128 new certifications per year, a downsizing of 1182, or 20% was indicated. Only family practice, neurosurgery, otolaryngology, and urology did not require downsizing. Seventeen medical and hospital-based specialties, including 7 of 10 internal medicine subspecialties, needed downsizing by at least 40%. Less downsizing in general was needed in the surgical specialties and in psychiatry. A managed care dominated-system would call for greater downsizing in most of the non-primary care specialties. CONCLUSION: These data support the need for downsizing the nation's physician supply, especially in the internal medicine subspecialties and hospital support specialties and to a lesser extent among surgeons and primary care physicians.

Health Services Needs and Demand↗

PubMed2002

Population-based outcomes after acute antenatal transfer.

Acute antenatal transfer to specialist centres is an accepted practice but few or no regular data are collected regarding the numbers of transfers performed or subsequent pregnancy outcome. We wished to determine the numbers, and the maternal and fetal outcomes following acute antenatal transfer between consultant obstetric units in the former Northern Region of the UK over a 12-month period (1 January-31 December 99). This is a geographically defined population in terms of provision of perinatal services. All acute antenatal transfers were notified centrally. Data pertaining to each transfer were collected at the time of transfer. Subsequent maternal and fetal outcomes were determined from patient records and neonatal databases. The regional annual acute antenatal transfer rate was 3.7 per 1000 deliveries. Most were for fetal reasons, although transfer rates varied between hospitals. The decision to transfer was influenced by distance and availability of paediatric staff. Even units that have similar characteristics show considerable variation in their transfer rates. No adverse incidents occurred during transfer and no major changes in maternal management occurred following transfer. Twenty-four per cent of women remained undelivered following transfer. Women with preterm labour in the absence of ruptured membranes were less likely to deliver than those transferred for other reasons and if they did deliver, their infants were also less likely to need intensive care. We believe audit of acute antenatal transfers should be routinely undertaken. Numbers of transfers might be reduced if delivery and the need for neonatal intensive care could be predicted with greater accuracy. The psychological and financial costs of transfer to women and healthcare providers need to be addressed.

Female↗

PubMed2003

Controlled trial of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes.

OBJECTIVE: Despite good evidence and clinical practice guidelines, studies document that treatment of type 2 diabetes is less than optimal. Lack of resources or limited access may put patients in rural communities at particular risk for suboptimal care. RESEARCH DESIGN AND METHODS: We conducted a prospective, before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service (intervention) for improving the quality of care for rural patients with type 2 diabetes. Our intervention consisted of six monthly visits by a traveling team of specialist physicians, nurses, dieticians, and a pharmacist. The core of this service was specialist-to-rural primary care physician academic group detailing. Two comparable regions in Northern Alberta were randomly allocated to control or intervention. Data were collected before and 6 months after intervention in a representative volunteer sample. The primary outcome was a 10% improvement in any one of the following: blood pressure, total cholesterol, or HbA(1c). RESULTS: Our analysis included 200 intervention and 179 control subjects; 14 subjects were at all three primary outcome targets at baseline. The intervention was associated with a trend toward improvement in primary outcome at 6 months (44% intervention vs. 37% control; odds ratio 1.32, 95% CI 0.87-1.99). The intervention was associated with a significant improvement in blood pressure (42% intervention vs. 25% control, P = 0.004); however, there were only small, nonsignificant changes in cholesterol or HbA(1c). The intervention was associated with a significant increase in satisfaction with diabetes care. Multivariate adjustment for baseline differences between intervention and control subjects did not affect any of the main results. CONCLUSIONS: A diabetes outreach service has the potential to improve the quality of diabetes care for rural patients. Future studies need to involve longer timelines and larger sample sizes.

Aged↗

PubMed2004

An evaluation of prompt access to physiotherapy in the management of low back pain in primary care.

BACKGROUND: Disability arising from low back pain (LBP) is a growing problem. Current primary care management of LBP has been criticized for its mechanistic basis and for delays in gaining access to specialist advice. Among recent recommendations made for improved management are functional explanatory models, a rehabilitative approach and early access to physical therapy. It is not known if these recommendations can be implemented in mainstream primary care. OBJECTIVE: The purpose of our study was to examine the feasibility, acceptability and component costs of providing a prompt access physiotherapy service for new episodes of LBP in primary care; to describe outcomes and compare them with other published interventions; and to explore the influence of the service on GPs' approach to LBP. METHODS: Back pain clinics staffed by a physiotherapist were established in a group of demographically representative practices in a typical UK health authority. Adult patients with a new episode of LBP referred by their GPs were managed in accordance with recent recommendations. Data on pain, disability and well-being were collected at recruitment and some 12 weeks later. Patient diaries and interviews with GPs before and after the study provided qualitative data. Comparative costings were derived from national and local sources. RESULTS: A total of 614 patients, representing 3.2% of the adult population, were referred, of whom 522 (85%) were seen at the back pain clinics within 3-4 days, the majority within 72 h. Although this represents less than half the adult patients thought to be presenting to their GPs with LBP, patients exhibited levels of pain and disability comparable with those described in other studies of LBP in primary care. More than 70% of patients required only a single clinic visit and <5% were referred on to specialist orthopaedic or back pain rehabilitation services. At follow-up, levels of improvement were comparable with and time taken off work superior to those seen in other intervention studies of LBP in primary care. Prompt access to physiotherapy in primary care costs less per episode of LBP than conventional management. Qualitative data suggest that patients valued early access to the physiotherapist, particularly for the reassurance provided. Interviews with GPs revealed strong support for the service, in large part based on favourable feedback from patients. CONCLUSIONS: For primary care patients with a new episode of LBP referred by their GP, prompt access to a dedicated physiotherapy service is both feasible and acceptable. Comparison with other published interventions suggests that it is also cost-effective and that a typical Primary Care Trust (PCT) would rapidly recoup the cost of additional physiotherapists. However, questions remain about the availability of sufficient physiotherapists to make such a service available nationally. The influence of the service upon GPs' own approach to the management of LBP is likely to be gradual and to come about largely through positive feedback from patients.

Adolescent↗

PubMed2005

Inpatient management of asthma in the Chicago suburbs: the Suburban Asthma Management Initiative (SAMI).

BACKGROUND: Assessment of inpatient asthma management has generally been limited to urban settings, including Chicago, which is known for its high asthma morbidity and mortality. Previously published data have been based on survey methodology. The Suburban Asthma Consortium (SAC) sought to obtain patient-based data unique to the Chicago suburbs to improve asthma care in those areas. OBJECTIVE: To evaluate current inpatient asthma management based on the 1997 National Asthma Education and Prevention Program (NAEPP). DESIGN: Retrospective chart review of all hospitalized patients 3-65 years bearing asthma-related ICD-9 codes for fiscal year 2002 in community, nonteaching hospitals in Chicago suburbs. RESULTS: Nine hundred two cases were submitted from seven hospitals. The majority ( > or = 75%) received inhaled bronchodilators, systemic steroids, oxygen and pulse oximetry. Antibiotic use (67%), chest radiography (85%), complete blood count (77%), and electrolytes (59%) appeared excessive in view of NAEPP recommendations. Peak flow monitoring (PFM) was recorded on admission in 45% of patients 5 years old and older; 52% had PFM during hospitalization. Thirty-eight percent of patients were taking ICS prior to admission; of those not on ICS, only 12% were newly diagnosed asthmatics. Overall, 51% of patients were discharged with ICS. Patients were more likely to receive ICS at discharge if they had required intensive care (ICU), had been on ICS prior to admission, were referred to an asthma specialist while hospitalized, or were insured. Patients with Medicare/Medicaid (MC/MA) had more repeat emergency visits and hospitalizations, longer lengths of stay, and received less ICS at discharge. Depending on the parameter, 41% or less patients received discharge planning education and were not more likely to have received education if in the ICU. Results ranged significantly between hospitals for most parameters (p < 0.05 or less). CONCLUSION: Study subjects received appropriate acute therapy and oxygen monitoring, but there was a divergence from NAEPP recommendations regarding PFM, ICS use, antibiotics, and laboratory evaluation. Patients receiving MC/MA experienced higher morbidity and received less ICS. Discharge asthma education was suboptimal for most hospitals. Most parameters demonstrated significantly wide practice variations between hospitals. Peak flow monitoring and patient education findings differed significantly from those in survey-conducted studies.

Adolescent↗

PubMed1997

[An observation on tuberculosis associated with HIV infection in Japan].

OBJECTIVE: To observe the reported cases of tuberculosis (TB) with HIV infection in Japan, in terms of their main clinical features and related factors. METHODS: A voluntary reporting network has been organized by the authors who are specialists of TB or respiratory medicine in tuberculosis institutions located roughly all over the country. The members have been encouraged to report not only their own cases but cases seen by their friends or in other institutions. RESULTS: By the end of 1996, a total of 71 cases have been reported of which 59 were TB and 12 NTM cases. Nationality of the cases were; Japan 48, Other Asian countries 16, Others 7. All of the NTM cases were Japanese. 30% of the cases were aged less than 30 years, 24% were thirties, 24% forties, 17% fifties and 6% were those aged 60 years or older. The cases were clearly younger than the TB cases in the national TB registry, and older than HIV-infected persons as known from the HIV surveillance system. 97% of the TB cases were bacteriologically confirmed cases. Eight of NTM cases were positive for MAC, others for M.kansasii. 42% of the cases had extra-pulmonary disease, including disseminated infections seen among 19%. Of TB cases 25% were excreting bacilli resistant to any of the anti-TB drugs which was higher than in the case of general TB population (10-15%). 11% of TB cases had past history of TB treatment. The cases had severe immunological impairment, 79% of the cases having CD4+ cell count less than 100. The route of HIV infection were; 51% heterosexual, 13% homosexual, 13% through blood preparations, etc. DISCUSSION: Although there may be many cases not included in this observation, it is considered to well reflect the real situation of the problem of Japan. More attention should be paid to HIV infection of the patients in the clinical practice of TB in Japan.

AIDS-Related Opportunistic Infections↗

PubMed1995

Contraceptive services for teenagers: do we need family planning clinics?

OBJECTIVE: To determine whether the effectiveness of contraceptive services for teenagers is related to the balance of service provision between general practitioners and specialist family planning services. DESIGN: Cross sectional study with routinely collected data from family planning clinics and family health services authorities and published data on births and abortions. SETTING: Eight health districts in the former Oxford region. SUBJECTS: Girls aged under 16 and women aged 16-19 who attended a contraceptive service during 1991-2 or who gave birth or had an abortion during 1990-2. MAIN OUTCOME MEASURES: Attenders at family planning clinics as a percentage of all users of contraceptive services. The conception rate:uptake of contraceptive services ratio was used as a measure of effectiveness. RESULTS: In comparisons between districts the percentage of all users of contraceptive services who attended a clinic varied from 38% (95% confidence interval 28% to 48%) to 79% (72% to 86%) among 13-15 year olds and from 14% (12% to 15%) to 44% (42% to 46%) among women aged 16-19 years. The conception rate: uptake of contraceptive services ratio varied twofold in the older age group and more than threefold in the younger age group. It was lowest in districts where clinic attenders comprised a large percentage of all users of contraceptive services. CONCLUSION: Contraceptive services for teenagers may be more effective in districts where clinics play a large part in delivering the service, particularly for girls aged under 16.

Abortion, Induced↗

PubMed1993

Ethnicity as a risk factor for consultations in primary health care and out-patient care.

OBJECTIVE: To determine the influence of ethnicity, defined as foreign-born people, on consultation rates, admissions and prescriptions in out-patient care and primary health care. DESIGN: Prospective study of attenders at four different caregivers during seven consecutive weeks in 1988. Age-and sex-standardized relative risks and odds ratios with 95% confidence interval were calculated. SETTING: A suburban area in Lund, a city located in the south of Sweden, with 28% foreign-born people. SUBJECTS: This population (N = 5085) made 1,348 consultations. MAIN OUTCOME MEASURES: Ethnic group and consultation rates of the local primary health care centre, the emergency department, hospital out-patient department, and private care, admissions to specialist care, prescriptions, and certified sick leave. RESULTS: Swedes made fewer age-and sex-standardized visits to the emergency department (RR = 0.69(0.48-0.99)) while the foreign-born people showed an opposite non-significant trend (RR = 1.37(0.95-1.99)). Latin Americans (RR = 1.60(1.02-2.51)) visited the local Primary Health Care centre in the residential area more than expected, while people born in Asia and Africa consulted the Primary Health Care centre less than expected (RR = 0.44(0.28-0.69)). There were no differences between Swedes and foreign-born people in being put on the sick-list, but foreign-born people were given significantly fewer prescriptions (RR = 0.07(0.03-0.19)) than Swedes. Foreign-born people, Latin Americans, and non-Swedish Scandinavians were referred significantly more often to hospital than other groups. CONCLUSIONS: There were important differences in consultations between Swedes and foreign-born people. It seems important to study these differences further to find out if they were due to morbidity or cultural differences in order to be able to meet the demands and needs of different ethnic groups.

Africa↗

PubMed2005

The design of the Dutch EASYcare study: a randomised controlled trial on the effectiveness of a problem-based community intervention model for frail elderly people [NCT00105378].

BACKGROUND: Because of their complex clinical presentations and needs frail elderly people require another approach than people who age without many complications. Several inpatient geriatric health services have proven effectiveness in frail persons. However, the wish to live independently and policies that promote independent living as an answer to population aging call for community intervention models for frail elderly people. Maybe models such as preventive home visits, comprehensive geriatric assessment, and intermediate care qualify, but their efficacy is controversial, especially in frail elderly persons living in the community. With the Dutch EASYcare Study Geriatric Intervention Programme (DGIP) we developed a model to study effectiveness of problem based community intervention models in frail elderly people. METHODS/DESIGN: DGIP is a community intervention model for frail elderly persons where the GP refers elderly patients with a problem in cognition, mood, behaviour, mobility, and nutrition. A geriatric specialist nurse applies a guideline-based intervention with a limited number of follow up visits. The intervention starts with the application of the EASYcare instrument for geriatric screening. The EASYcare instrument assesses (instrumental) activities of daily life, cognition, mood, and includes a goal setting item. During the intervention the nurse regularly consults the referring GP and a geriatrician. Effects on functional performance (Groningen Activity Restriction Scale), health related quality of life (MOS-20), and carer burden (Zarit Burden Interview) are studied in an observer blinded randomised controlled trial. 151 participants were randomised over two treatment arms--DGIP and regular care--using pseudo cluster randomisation. We are currently performing the follow up visits. These visits are planned three and six months after inclusion. Process measures and cost measures will be recorded. Intention to treat analyses will focus on post intervention differences between treatment groups. DISCUSSION: The design of a trial evaluating the effects of a community intervention model for frail elderly people was presented. The problem-based participant selection procedure satisfied; few patients that the GP referred did not meet our eligibility criteria. The use of standard terminology makes detailed insight into the contents of our intervention possible using terminology others can understand well.

Activities of Daily Living↗

PubMed2001

Effects of Medicaid managed care on health care use: infant emergency department and ambulatory services.

OBJECTIVE: Many urban children rely on emergency departments (ED) for ambulatory care. The objective of this study was to determine whether enrollment in Medicaid managed care (MMC) alters ED or other ambulatory care compared with fee-for-service Medicaid (FFSM). METHODS: A prospective cohort study of infants born between May 1994 and April 1995 with a 6-month follow-up period was conducted in an urban, teaching hospital and surrounding ambulatory settings. A consecutive sample of 644 infants enrolled in MMC or FFSM was studied; 92% of eligible patients were enrolled, and 94% completed follow-up. The main outcome measures were 1) proportion of patients in each group visiting an ED, primary care practitioner (PCP), or specialist; 2) mean number of visits per group; and 3) ED reliance (EDR) defined as the proportion of all ambulatory visits occurring in an ED. RESULTS: Fifty-six percent of MMC and 54% of FFSM patients visited an ED (relative risk: 1.03; 95% confidence interval [CI]: 0.83, 1.27). More MMC patients had a sick visit to their PCP (relative risk: 1.34; 95% CI: 1.03, 1.74); no difference in proportion with well-child or specialty visits was found. Although the mean number of total ambulatory, ED, and specialty visits was the same, MMC patients had fewer well-child and more sick visits to the PCP than FFSM patients (P =.01). EDR was 21% for both groups (P =.95). After adjustment for other factors in multivariate analysis, insurance status remained unassociated with EDR (adjusted odds ratio [OR]: 0.91; 95% CI: 0.56, 1.69). Factors associated with EDR included United States-born mother (OR: 5.34; 95% CI: 1.61, 17.68) and use of a hospital-based primary care physician (OR: 2.00; 95% CI: 1.34, 2.98). Variables that characterized infants who were less likely to be ED reliant included adequate maternal prenatal care (OR: 0.52; 95% CI: 0.34, 0.78) and having a mother who completed high school (OR: 0.67; 95% CI: 0.45, 0.99). CONCLUSIONS: Enrollment in MMC did not alter ED usage patterns when compared with FFSM. Some variation in use of other ambulatory services was detected.

Ambulatory Care↗

PubMed2001

EMR based telegeriatric system.

INTRODUCTION: As medical services improve due to new technologies and breakthroughs, it has lead to an increasingly aging population. There has been much discussion and debate on how to solve various aspects such as psychological, socioeconomic and medical problems related to aging. Our effort is to implement a feasible telegeriatric medical service with the use of the state of the art technology to deliver medical services efficiently to remote sites where elderly homes are based. Telegeriatric system will lead to rapid decision-making in the presence of acute or subacute emergencies. This triage will also lead to a reduction of unnecessary admission. It will enable the doctors who visit these elderly homes on a once-a-week basis to improve their geriatric management skills by communication with geriatric specialist. Nursing skills in geriatric care will also benefit from this system. Integrated EMR service will be indispensable in the face of emergency admissions to hospitals. Evolution of EMR database would lead to future research in telegeriatrics and will help to identify the areas where telegeriatrics can be optimally used. METHODOLOGY: This system is based on current web browsing technology and broadband communication. EMR web based server is developed using Java Technology. EMR database was developed using Microsoft SQL server. Both are based at the Medical Informatics Programme, National University of Singapore. Two elderly homes situated in the periphery of Singapore and a leading government hospital in geriatric care has been chosen for the project. These three institutions and National University of Singapore are connected via ADSL protocol, which support high bandwidth, which is necessary for high quality videoconferencing. Each time a patient needs a teleconsultation, a nurse or doctor in the remote site sends the history to the EMR server. EMR server forwards the request to the Alexandra Hospital for consultation. Geriatrics specialists at Alexandra Hospital carry out teleward rounds twice weekly and on demand basis. SUMMARY OF RESULTS: Following the implementation of the system, a trial run has been done. This shows a high degree of coordination and cooperation between remote site and the Alexandra Hospital Also the patient compliance is very high and they prefer teleconsultation. CONCLUSION: Initial results show that telegeriatric system has definite advantages in managing geriatric patients at a remote site. As the system evolves, further research will show the areas where telegeriatrics can be used optimally.

Aged↗

PubMed1997

Effects of self-care education on the health status of inner-city patients with osteoarthritis of the knee.

OBJECTIVE: To evaluate a concise program of self-care education delivered by an arthritis nurse specialist as an adjunct to primary care for inner-city patients with knee osteoarthritis (OA). METHODS: An attention-controlled clinical trial; 211 inner-city patients with knee OA were assigned arbitrarily to education (E) or attention-control (AC) conditions. Group E received an individualized 30-60-minute educational intervention that emphasized nonpharmacologic management of joint pain, preservation of function by problem-solving, and practice of principles of joint protection. Brief telephone contacts 1 week and 4 weeks later monitored and reinforced new self-care activities. Group AC viewed a 20-minute standardized public education presentation on arthritis and received followup telephone calls (only to encourage continued participation in the study). Outcomes included the Health Assessment Questionnaire (HAQ) Disability and Discomfort Scales, 10-cm visual analog scales measuring knee pain at rest and while walking, and the Quality of Well-Being (QWB) scale. Assessments were made at baseline and at 4-month intervals for 1 year. RESULTS: A total of 165 subjects (78%) completed all assessments. After control for baseline status, group E had significantly lower scores for disability and resting knee pain throughout the year of postintervention followup (P < 0.05 for both). Effects were somewhat discordant. By 12 months, functional benefits had begun to wane, while the effect on resting knee pain had grown. The overall effects of education on walking knee pain, overall joint pain (by HAQ), and general health status (by QWB) were not significant. CONCLUSION: Self-care education for inner-city patients with knee OA, delivered as an adjunct to primary care, was found to result in notable preservation of function and control of resting knee pain. The magnitude of the observed effects compares well with those of more labor-intensive and time-consuming intervention models. However, more sustained preservation of function and consistent effects on pain may require prolonged, more proactive followup, either by the patient educator or by a trained clinical assistant dedicated to the task of supporting self-care by patients with knee OA.

Aged↗

PubMed2004

Continuity through best practice: design and implementation of a nurse-led community leg-ulcer service.

The design of the new service was intended to facilitate continuity. The results after the first year of the new service revealed that care was both more effective and more efficient for all types of leg ulcers (Harrison, Graham, Friedberg, & Lorimer, 2003). Healing rates had dramatically improved, the frequency of nursing visits decreased, and supply costs declined. With the new service, comprehensive standardized assessments are made at baseline on all new admissions for home leg-ulcer care, and reassessments are regularly scheduled if the condition does not improve. With the evidence-based protocol, all providers and sectors of care are "working from the same script." Specific information is obtained on the client's health history, leg-ulcer history, preferences, and social context. Continuity is further facilitated through implementation of the primary nurse model, whereby one provider is responsible for developing the care plan and for subsequent evaluation and revision. Management continuity is advanced through health-care reorganization, with the development of an expert, dedicated nursing team, a consistent approach to training and skill development, improved coordination, an interdisciplinary approach for referral and consultation, and continuous quality improvement measures for education and practice audit. A number of strategies tailored to the new service have been highly effective. Strategic alliances among the researchers, home-care authority, nursing agency, nurses, and physicians are essential to the success of both design and implementation. Ongoing interdisciplinary and intersectoral communication expedites the referral process and helps to resolve issues as they develop. The majority of physicians have been very supportive of the use of the protocol and the evidence-based service. Surveys of care recipients have been mostly positive. Nurses who have been surveyed concerning the supports to implementation of the evidence-based service have indicated the following supports: ongoing education, nursing knowledge, a supportive clinical leader, support from two specialist physicians (a dermatologist and a vascular surgeon), a dedicated nursing team, positive outcomes (improved healing rates), and regional home care and agency support. The greatest challenge has been establishing and maintaining the dedicated nursing team. Continuity is served when nurses are assigned exclusively to the leg-ulcer team, where they can continue to build expertise and skills. The nursing agency was initially reluctant to embrace the concept of a dedicated team, as it viewed wound care as a general function of all nurses. Many of the nurses trained in leg-ulcer care fulfilled a number of other specialized nursing functions. This had resource implications for the nursing agency, as other nurses needed training in various other specialized skills. There should be a balance between the size of the population being served and the size of the team, in order to maintain efficiency and sufficient exposure to skilful assessment and management of leg-ulcer care. During the first year of the leg-ulcer service a number of nurses were lost from the team for various reasons, including: outside opportunities for career advancement, the physical demands of this type of care, retirement, moving from the area, and lack of job security. In addition, the volume of nursing visits was decreased because of Ontario government cutbacks in the area of home-care services. New staff members on the team were laid off in the context of a unionized environment. The lack of long-term security and the reality of lower wages in the community sector have played havoc with recruitment and retention. A recently formed committee at the nursing agency on continuity of care, with representation from nursing, management, and administration, has identified a number of further barriers to continuity. These include fluctuating caseloads, difficulty attracting nurses to the community sector, and a unionized environment in which senior nurses displace junior nurses on low-caseload days. Strategies aimed at overcoming the barriers to continuity have been identified and are being implemented. Our experience confirms the need for evidence-based planning in order to understand the needs of the population with leg ulcers, current practices, and the organization of care prior to the restructuring of service delivery. The extensive needs assessment indicated the need for broad system changes in addition to adjustments in clinical care in order to meet best-practice guidelines. Despite ongoing barriers, the service model has improved continuity and dramatically increased the effectiveness and efficiency of leg-ulcer care in one community.

Benchmarking↗

PubMed1999

Evaluation of the efficacy of a hospital-based asthma education programme in patients of low socioeconomic status in Hong Kong.

BACKGROUND: Good asthma control requires optimal medical treatment in conjunction with appropriate self-management. In the West, the effectiveness of patient education on improving self-management has been well documented. However, data amongst Asian populations are lacking. We performed a pilot study to evaluate the efficacy of a hospital based education programme aimed at improving self-management skills and reducing morbidity in a Chinese population with low socioeconomic status and education level. METHODS: Our asthma education programme was a low-cost programme conducted in essence by specialist respiratory nurses. Patients attending our asthma clinic were instructed during a two-hour educational session on the pathophysiology of asthma, its potential triggers, the appropriate use of medications including proper inhaler techniques, and the self-management of their disease. These instructions were reinforced by video sessions at subsequent outpatient clinic attendance when patients' inhaler and peak flow techniques were checked by the same nurses and their self-management plan re-examined by the attending physicians. Asthma knowledge, inhaler technique, FEV1 and peak expiratory flow (PEF), and patients' self-rating of their asthma were determined at baseline, 6 months and 1 year after the intervention. Morbidity was assessed by the numbers of hospitalizations, unscheduled visits to family physicians and accident and emergency department attendance, courses of oral steroid used and days off work or school at baseline and 1 year. RESULTS: Two hundred and thirty patients were recruited for the study, 83% completing the entire assessment period. The group demonstrated significant improvements in lung function: the mean FEV1 +/- SD increased from 63.6 +/- 20.6% of predicted values at baseline to 68.5 +/- 22.3% at 6 months and 68.6 +/- 22.8% at 1 year (P < 0.05), and the mean PEF +/- SD increased from 64.6 +/- 23.0% of predicted values at baseline to 75.4 +/- 27.0% at 6 months and 76.8 +/- 24.5% at 1 year(P < 0.001). There were also significant improvements in inhaler technique (P < 0.01), asthma knowledge (P < 0.001), patients' self-rating of their asthma (P < 0.05), and reductions in the numbers of hospitalizations (P < 0.01), visits to family physicians (P < 0.001) and accident and emergency department attendance (P < 0.001) during the study period. Patients with moderate to severe asthma as defined by an FEV1 of < 80% of predicted values were most likely to benefit from the programme. CONCLUSIONS: We conclude that patient education is likely to be an essential component in the holistic approach to the management of asthma even amongst Asian populations of low socioeconomic status and education level. Further studies using randomised controlled trials are necessary to consolidate our findings.

Administration, Oral↗