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PubMed2002

Heavy users of acute psychiatric beds: randomized controlled trial of enhanced community management in an outer London borough.

BACKGROUND: Heavy users of psychiatric services, often defined as the population that uses the most beds, consume a large part of the resources used by the whole service, despite being relatively small in number. Any intervention that reduces heavy use is therefore likely to lead to significant savings, and enhancement of standard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group. METHODS: The effectiveness of enhanced community management (ECM) was compared with standard care alone in heavy users, who represented the 10% of patients with the highest number of hospital admissions and occupied bed days over the previous 6.5 years in an outer London borough. One hundred and ninety-three patients were randomly assigned to ECM or standard care and their use of services was determined after 1 and 2 years, with assessments of costs, clinical symptoms, needs, and social function made before entry into the study and after 1 and 2 years. RESULTS: Despite a 24 fold increase in community contacts in the study group, there were no significant differences between the two groups in any of the main outcome measures. Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM. Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups. CONCLUSIONS: Providing additional intensive community focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care.

Adolescent↗

PubMed2001

Patient and physician satisfaction with telemedicine for monitoring vital signs.

We evaluated user satisfaction with realtime telemedicine for monitoring vital signs. Over eight weeks, 20 patients and 12 residents in family medicine participated in the study. At the end of the study, the patients and doctors completed a questionnaire detailing satisfaction with the service. Responses were obtained from 18 of the 20 patients and were generally positive: 61% were comfortable using the system and 94% did not believe that the technology had a negative effect on their relationship with the health-care provider. Eleven physician responses were obtained. Physicians were more uncertain about the benefits of the service: only 45% felt that telemedicine could adequately assess patients, although 82% felt that telemedicine would be an important part of primary-care services. From a user perspective, our study showed that patients were more satisfied with the telemedicine service than were doctors.

Aged↗

PubMed2005

Is the statistical association between sex and the use of services for mental health reasons confounded or modified by social anchorage?

OBJECTIVE: Confounding and interaction have differing implications for the interpretation of findings and the design of research, mental health services, and policy. This study aimed to verify whether the association between sex and the use of services for mental health reasons is confounded or modified by social anchorage. METHODS: We undertook a case-control study nested in Cycle 1.2 of the Canadian Community Health Survey. Cases were defined as users of general medical services for mental health reasons in the previous 12 months, and control subjects were defined as never-users of any services for mental health reasons. The pattern of social anchorage was described by the roles of parent, spouse, worker, and their combination. RESULTS: Overall, women are 2.9 times more likely than men to use general services for mental health reasons. However, this inequality between women and men decreases substantially or subsides in individuals who are less anchored to Canadian society. For instance, in single parents and in unemployed parents, the odds of using general services for mental health reasons are similar in women and in men. The pattern of social anchorage tends to modify, but not to confound, the association between sex and the use of services. CONCLUSIONS: Ignoring the interaction between sex and the pattern of social anchorage distorts the interpretation of the inequality between women and men in the use of general medical services for mental health reasons and may affect the design of comprehensive mental health services and policy.

Adolescent↗

PubMed2000

A comparison of levels of satisfaction of stable drug users treated in general practice and an outpatient (community based) drug treatment service.

The objective of the study was to compare levels of satisfaction in stable drug users treated in general practice (GPTG) and a community based outpatient treatment service (OPTG). The study is in two parts. Part 1: Twenty preliminary interviews were undertaken with drug users attending treatment services at an outpatient clinic (n = 12) and with their general practitioner (n = 8). A questionnaire was developed employing a delight-terrible scale and simple agree/disagree questions based on the areas identified in the interviews. Descriptive and inferential statistics were used to analyse the data. Part 2: Subjects were recruited from eight general practitioner (GP) surgeries and two outpatient clinics in the North-west of England. Seventy-three clients cared for by their GP and 97 clients of the outpatient clinics completed the questionnaire. All clients were receiving 70 mLs of oral methadone (1 mg per ml) and no other prescribed medication. The results of these data indicate that clients managed by their GP show a greater level of 'satisfaction' with the treatment they received from their GP, the prescription they had and report a better emotional state than those treated in a specialist outpatient unit. Clients managed by their GP also reported a greater satisfaction with the relationship they had with the prescribing doctor and the contact associated with this. They perceived help to be more readily available to them than a similar group treated in a specialist service did. These differences occur even though there are only slight variations between the groups in variables related to positive outcomes in drug treatment. The results of this study represent the client's perspective on treatment, using measures that they see as important to them. As such this study adds to the growing body of information about where drug treatment services should be located.

Journal Article↗

PubMed2000

Home care users' experiences of fiscal constraints. Challenges and opportunities for case management.

With mounting fiscal constraints in home care, case managers find themselves increasingly confined in rationing roles and pressed into a narrow focus on the individual case. These pressures frustrate case management's potential to inform and contribute to more broadly-based improvements in service systems, policy formulation, and resource development. A study of home care users' perspectives in a jurisdiction where fiscal pressures have been rapidly increased reveals how rationing and service reduction affect service recipients and shape their relationships with case managers. The study sheds light on the challenges and opportunities for case managers of practicing in such straitened circumstances. Combined with their own detailed understanding of front-line service delivery, case managers can build on the knowledge of service users' perspectives to make critical contributions to both the well-being of the generally jeopardized populations who need home care and to the broadening of case management practice in keeping with its commitments to advocacy and systems level change.

Adult↗

PubMed1993

Wartime military service and utilization of VA health care services.

This study sought to examine predisposing, enabling, and illness characteristics associated with use of Department of Veterans Affairs (VA) health care services. In view of VA's unique mission to care for war veterans, special attention was given to features of wartime military service as predisposing factors for VA health care use. Data from a 1987 national survey of veterans were used to compare VA users and non-users. Logistic regression analysis was used to identify specific variables independently associated with VA health service use. Among current VA health service users, 55% served in combat and 71% in a war zone. Multivariate analysis showed that high illness level, service-connected disability status, and lack of health insurance are the strongest predictors of VA service use. Significant associations were also found between military service during a wartime era, in a war zone, and in combat, and VA health service utilization. Although no differences were noted in VA health service use between veterans of different wartime eras, it was notable that among Korean War-era veterans alone, war zone and combat exposure were not associated with increased VA health service use, perhaps reflecting the more limited public attention that has been paid to veterans of that war. Veterans with war-related military experience show a distinct affinity for VA services.

Health Services Accessibility↗

PubMed1993

Computer use in private dental practice in Australia, 1991.

There was a 70 per cent response to a mail questionnaire to a 1:3 sample of Australian Dental Association members in private practices (n = 1931). Computers were used by 37 per cent of practices. Main computer applications used were for: accounting (84%); patient billing (80%); word processing (79%); and patient recall (61%). External bureau services were used by 4 per cent of practices with most computers being in-house (single terminal 66%; multiple terminal 33%). The more dentists in a practice, the more likely was a computer to be used. Principal users were secretary/receptionists. Service and software were the most important factors in choice of computer system. Many practice computer users (67%) also had a Personal Computer at home compared with only 36 per cent of the non-users. Many respondents indicated the need for continuing education in computers (67% users; 61% non-users). More than half of the non-users indicated future use of computers for accounting, billing and recall. There has been a considerable increase in the use of computers in private practice (37%) since the Australian Dental Association Dental Practice Survey in 1983/84 (9%).

Age Factors↗

PubMed1999

Maintaining continuity of clinical operations while implementing large-scale filmless operations.

Texas Children's Hospital is a pediatric tertiary care facility in the Texas Medical Center with a large-scale, Digital Imaging and Communications in Medicine (DICOM)-compliant picture archival and communications system (PACS) installation. As our PACS has grown from an ultrasound niche PACS into a full-scale, multimodality operation, assuring continuity of clinical operations has become the number one task of the PACS staff. As new equipment is acquired and incorporated into the PACS, workflow processes, responsibilities, and job descriptions must be revised to accommodate filmless operations. Round-the-clock clinical operations must be supported with round-the-clock service, including three shifts, weekends, and holidays. To avoid unnecessary interruptions in clinical service, this requirement includes properly trained operators and users, as well as service personnel. Redundancy is a cornerstone in assuring continuity of clinical operations. This includes all PACS components such as acquisition, network interfaces, gateways, archive, and display. Where redundancy is not feasible, spare parts must be readily available. The need for redundancy also includes trained personnel. Procedures for contingency operations in the event of equipment failures must be devised, documented, and rehearsed. Contingency operations might be required in the event of scheduled as well as unscheduled service events, power outages, network outages, or interruption of the radiology information system (RIS) interface. Methods must be developed and implemented for reporting and documenting problems. We have a Trouble Call service that records a voice message and automatically pages the PACS Console Operator on duty. We also have developed a Maintenance Module on our RIS system where service calls are recorded by technologists and service actions are recorded and monitored by PACS support personnel. In a filmless environment, responsibility for the delivery of images to the radiologist and referring physician must be accepted by each imaging supervisor. Thus, each supervisor must initiate processes to verify correct patient and examination identification and the correct count and routing of images with each examination.

Computer Communication Networks↗

PubMed2005

Existing demand for birth spacing in developing countries: perspectives from household survey data.

OBJECTIVE: To identify the extent of demand for birth spacing, according to age and parity among married women of reproductive age (MWRA) in developing countries. METHODS: Secondary analysis of data from the Demographic and Health Surveys (DHS) using cross-tabulations. Data collected from nationally representative samples of MWRA in selected developing countries between 1990 and 2004. RESULTS: Demand for birth spacing is the most prevalent reason for an interest in family planning among married women aged 15-29 years in the majority of developing countries examined. In the 15-19-year age cohort, the demand for spacing is proportionally the most prevalent reason for a demand for family planning. A demand for spacing even exists among young, zero-parity married women in each country examined. Findings on the demand for spacing among zero-parity married women quantifies the expressed desire of some married women in developing countries to postpone a first birth or the timing of a first pregnancy. CONCLUSION: The substantial demand for birth spacing among young, low- and zero-parity women suggests that family planning programs in developing countries may need to reevaluate how accessible services are for this cohort of potential contraception users. Currently, many service-delivery protocols, counseling practices and service provider training may not fully address the needs of younger, low- or zero-parity clients.

Adolescent↗

PubMed2006

More aspiration than achievement? Children's complaints and advocacy in health services in Wales.

The present paper reports on key results from a government-funded survey of all National Health Service trusts, local health boards and community health councils in Wales, which was conducted in 2004-2005 to identify the characteristics of complaints involving children, and the use of professional advocacy services in these complaints and their role in supporting children in relation to health service matters more generally. Findings from the survey are presented which reveal the marginal take-up of professional advocacy services in health complaints, and the slender resource in professional advocacy for children commissioned by a small number of health bodies. Advocacy support for users of health services typically focuses upon adult-related issues. The needs of children, particularly those who may have special requirements because of disability, being looked after, or having language or cultural needs are not well met according to the present survey. This raises the question of whether recent policy and guidance on advocacy (particularly for children and vulnerable groups) is seen by health bodies as warranting decisive action and dedicated investment, or whether rhetoric and modest change is the more likely outcome in the face of other pressing demands on health budgets.

Achievement↗

PubMed1982

Comparison of utilization of medical services by alcoholics and non-alcoholics.

To determine whether medical costs for alcoholics are higher than those for non-alcoholics, inpatient and outpatient costs for medical services of 191 alcoholics with 191 non-alcoholic matched controls were compared over four years. Results confirm that alcoholics are higher-cost users of medical services than non-alcoholics. (Am J Public Health 1982; 72:600-602.)

Alcoholism↗

PubMed2005

Establishment of vaccination clinics; user fees for investigational new drug (IND) influenza vaccine services and vaccines. Interim final rule and request for comments.

We are amending 42 CFR part 70 to establish vaccination clinics and a user fee in connection with the administration of vaccination services and vaccine. On December 7, 2004, HHS Secretary Tommy G. Thompson announced the purchase of 1.2 million doses of GlaxoSmithKline (GSK) influenza vaccine, Fluarix, for distribution to areas most in need as determined by State public health authorities. The Fluarix vaccine has been approved in seventy-eight foreign countries, and FDA has recently reviewed extensive manufacturing and summary clinical information and conducted an inspection of the GSK manufacturing facility in Germany to determine that this vaccine, although not licensed in the United States, is suitable for use under an Investigational New Drug application (IND). The Food and Drug Administration (FDA) reviewed GSK's IND application as well as the clinical protocol and manufacturing data. CDC and CDC's Institutional Review Board approved the GSK flu vaccine response protocol including the informed consent document. To ensure that the vaccine is properly administered to individuals identified to be most at risk and facilitate compliance with IND requirements, CDC is establishing vaccination clinics. CDC is proceeding without delay because of the unprecedented nature of this season's influenza vaccine shortage caused by contamination problems with Chiron Corporation's production facility in the United Kingdom, which effectively cut in half the expected United States supply of inactivated influenza vaccine. A user fee is being established in order to recoup the costs associated with administering the vaccine and for the vaccine itself. All individuals, other than those who are enrolled in Medicare Part B, will be required to pay the user fee.

Adolescent↗

PubMed1999

Meanings of community in a community health center.

As health care organizations make communities the targets for their interventions, connections between "community" as theory for practice and community as setting for practice require examination. This study s purpose was to explore meanings given to community in a newly formed community health center, with particular emphasis on the relationship among women, community, and health. Using interpretive and emancipatory methodologies, interviews were conducted with clinic administrators and staff, and women who used the clinic. Data analysis revealed discrepancies in meanings of community. Clinic personnel referred to community as the target for their services, while clinic users spoke about community as the process that made feeling connected with others possible. Health center staff and administrators described the community they were serving as having limited economic, educational, physical, and psychological resources and saw little which could be labeled a community strength. Health center users however, spoke primarily of their abilities to support each other. These contradictory understandings of the meaning of community rendered different expectations regarding health care services. Meanings given to community may de-personalize, homogenize, and objectify, and ultimately distance nursing from those intended to be served.

Adolescent↗

PubMed1987

Quality assurance program for a drug information center.

The objective of this study was to develop a quality assurance program for the drug information service using outcome measurements. Criteria of timeliness, accuracy, objectivity, completeness, and use of the information in patient care were measured by a questionnaire sent to users of the service. A response rate of 86 percent showed that the criteria were met in 92, 97, 92, 75, and 69 percent of cases, respectively. The autoreputational approach was utilized in altering procedures to attempt to meet the previously set standards. It was concluded that measuring outcome is a useful method for assuring the quality of a drug information service.

British Columbia↗

PubMed1988

Decree No. 17898-S of 2 December 1987.

This Decree, which is aimed at guaranteeing health care for all the people of Costa Rica, recognizes the right of persons insured by the State to receive, without direct payment, services to protect their health in the facilities of the Costa Rica Social Security Fund. A person insured by the State is defined as a user of health services not included in any of the schemes, categories, or agreements of the Fund and who cannot pay for health services. Further provisions of the Decree set forth rules on determining who is eligible to receive health services and the financing of such services, among other things.

Americas↗

PubMed2006

What do clinicians want from us? An evaluation of Brighton and Sussex University Hospitals NHS Trust clinical librarian service and its implications for developing future working patterns.

BACKGROUND: The Clinical Librarian (CL) Service at Brighton was established in 2003 with the aim of providing high-quality evidence to designated teams and fostering an evidence-based culture. OBJECTIVE: To evaluate the CL service at Brighton and discuss the implication of the findings. METHODS: A combination of internally collected data (n = 167), and an external evaluation of the service by questionnaires (n = 86) of users and non-users and interviews (n = 9) of users. RESULTS: Internal data suggest that the service is valued by its users and that patient care and continuing professional development are the most common uses for searches (confirmed by the external study); that searches generally result in some change in knowledge; and that this knowledge is disseminated. The external study found that visibility of the CL was crucial to the effectiveness of the role and that clinicians used the service mostly to get access to a wider range of resources and/or to save time. Users wanted the CL to include evaluative annotation with the results, and for the CL role to become more embedded in the team. Interview results expanded on the issues of integration of the CL and the need for annotation of results. CONCLUSIONS: To be most effective, CLs would be dedicated to one team, but financial constraints make this unlikely. Alternative working patterns are suggested as a possible compromise.

Access to Information↗

PubMed1996

Integrating Ecology into Natural Resource Management Policy

Traditional natural resource management policy has largely focused on implementing prescriptive solutions to maximize a production function. The fundamental assumptions of this approach were: (1) that ecosystems behaved in a linear, deterministic manner; (2) that there was general community agreement on the value of different ecosystem services; and (3) that land managers would accept and adopt the recommended technology. The result has generally been an unpredictable performance by ecosystems, conflicting expectations among users, and low adoption rates for the outputs of research and development (R&D). We propose that an approach that integrates the fundamentals of nonequilibrium ecology and "soft" systems methodologies to define options, make management decision recommendations, and implement programs will result in improved predictability of ecosystem response, more realistic expectations on the part of users of ecosystem services, and better uptake of technology by land managers.

Journal Article↗

PubMed2005

Does NHS Direct empower patients?

NHS Direct is a 24h telephone helpline established in England and Wales, UK to offer advice and information for people about health, illness and the National Health Service (NHS) so that they are better able to care for themselves and their families. In 2001/2002 we undertook in-depth home interviews with 60 users of the service in two NHS Direct sites in England. In this paper we consider the extent to which NHS Direct facilitates patient empowerment in terms of helping people to be in control of their health and health care interactions. Our research suggests that NHS Direct facilitates patient empowerment by enabling patients to self care and to access health advice and services. It is also seen to offer the prerequisites for empowerment perceived to be lacking in the wider NHS, including time, respect, listening, support, and information. The service also functions by offering an alternative contact point for people seeking to avoid being labelled 'time wasters' by other busy health care providers. In the context of a wider health service which appears to problematise individuals' ability to make decisions about the appropriateness of seeking health care, NHS Direct legitimises help-seeking actions. Empowerment in the context of NHS Direct has been associated with self care as a way of reducing 'unnecessary' demand on health services. However, health professional and patient perspectives on what is considered necessary demand differ, and in certain contexts, patient empowerment may involve service use as well as self care. Further, our data reveal the context-dependent nature of a concept like empowerment. For example, when people are ill, in pain, or anxious about a loved one, they may value being cared for more than being empowered. Our research suggests that, in addition to its other functions, NHS Direct is also valued as contributing to a sense of being cared for.

Adolescent↗