Referral of patients to an anticoagulant clinic: implications for better management.
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The quality of anticoagulant treatment of ambulatory patients is affected by the content of referral letters and administrative processes. To assess these influences a method was developed to audit against the hospital standard the referral of patients to one hospital anticoagulant clinic in a prospective study of all (80) new patients referred to the clinic over eight months. Administrative information was provided by the clinic coordinator, and the referral letters were audited by the researchers. Referral letters were not received by the clinic for 10% (8/80) of patients. Among the 72 referral letters received, indication for anticoagulation and anticipated duration of treatment were specified in most (99%, 71 and 81%, 58 respectively), but only 3% (two) to 46% (33) reported other important clinical information (objective investigations, date of starting anticoagulation, current anticoagulant dose, date and result of latest international normalised ratio, whether it should be the anticoagulant clinic that was eventually to stop anticoagulation, patients' other medical problems and concurrent treatment. Twenty two per cent (16/80) of new attenders were unexpected at the anticoagulant clinic. Most patients' case notes were obtained for the appointment (61%, 47/77 beforehand and 30% 23/77 on the day), but case notes were not obtained for 9% (7/77). The authors conclude that health professionals should better appreciate the administrative and organisational influences that affect team work and quality of care. Compliance with a well documented protocol remained below the acceptable standard. The quality of the referral process may be improved by using a more comprehensive and helpful referral form, which has been drawn up, and by educating referring doctors. Measures to increase the efficiency of the administrative process include telephoning the clinic coordinator directly, direct referrals through a computerised referral system, and telephone reminders by haematology office staff to ward staff to ensure availability of the hospital notes. The effect of these changes will be assessed in a repeat audit. (+info)
Sending parents outpatient letters about their children: parents' and general practitioners' views.
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Parents' cooperation is essential to ensuring implementation of effective healthcare management of children, and complete openness should exist between paediatricians and parents. One method of achieving this is to send parents a copy of the outpatient letter to the general practitioner (GP) after the child's outpatient consultation. To determine the views of parents and GPs a pilot survey was conducted in two general children's outpatient clinics in hospitals in Newcastle upon Tyne. In March and April 1991 a postal questionnaire was sent to 57 parents of children attending the clinics, and a similar questionnaire to their GPs to elicit, respectively, parents' understanding of the letter and perception of its helpfulness, and GPs' views on the value of sending the letters to parents. Completed questionnaires were received from 34(60%) parents and 47(82%) GPs; 26(45%) respondents were matched pairs. 27(79%) parents said they understood all of the letter, 19(56%) that it helped their understanding, 32(94%) felt it was a good idea, and 31(91%) made positive comments. In all, 29(61%) GPs favoured the idea and six (13%) did not. Eleven (23%) said they would be concerned if this became routine practice, and 20(74%) of the 27 providing comments were doubtful or negative; several considered that they should communicate information to parents. The views in the matched pairs were dissimilar: parents were universally in favour whereas many GPs had reservations. The authors concluded that sending the letters improved parents' satisfaction with communication, and they recommend that paediatricians consider adopting this practice. (+info)
Computerized tailored feedback to change cognitive determinants of smoking: a Dutch field experiment.
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In the last decade, attempts have been made to improve the efficacy of minimal interventions by tailoring them to individual features. In the development of these tailored interventions, it is important to know which information in interventions is essential. Most smoking cessation interventions contain information on the outcomes of quitting and skills to be used in a quit attempt. The present study was designed to assess the cognitive changes caused by both sorts of information. Therefore, 246 smokers who were planning to quit within 6 months were randomly assigned to three different conditions. In the first condition, the respondents received a computer-generated tailored letter on the outcomes of smoking cessation. In the second condition, the respondents received a computer-generated tailored letter containing self-efficacy enhancing information, mainly on skills. In both conditions, the contents of the letters were based on the pre-test scores of the participants. Participants in the control condition did not receive any cessation information. The results show that information on the outcomes of quitting changed expected outcomes while information on coping skills changed self-efficacy expectations, in comparison with the control condition. Comparing both experimental conditions, information on the outcomes led to changes in expected outcomes, whereas information on coping skills did not lead to higher self-efficacy expectations than information on the outcomes of quitting. It is concluded that the hypothesized effects were partly verified. (+info)
Long-term effectiveness of computer-generated tailored feedback in smoking cessation.
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Although tailored interventions consisting of only a few pages of information lead to more quitting than no intervention in the short term, the long-term efficacy of a single tailored intervention still has to be proven. In the present study smokers were reactively recruited and randomly allocated to one of four intervention conditions: (1) outcome information, (2) self-efficacy enhancing information, (3) both sorts of information or (4) no information. Smokers in the three experimental groups received computer-generated tailored feedback containing the condition-specific information, by mail. The results from the 14 months follow-up can be summarized as follows. Compared to the no information condition, all three experimental conditions led to significantly more smokers who had engaged in 24-h quit attempts. However, no experimental condition led to more 7-day quitting than the no information condition. With regard to continuous abstinence, the experimental condition offering a combination of outcome information and self-efficacy enhancing information had a significant effect, compared to the no information condition. It is concluded that a minimal six-page tailored intervention can be beneficial in supporting smokers to quit smoking, even after 14 months. (+info)
Using feedback letters to influence the use of antiulcer agents in a Medicaid program.
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OBJECTIVE: To determine the impact of printed patient-specific feedback regarding potential misprescribing of antiulcer agents (AUAs). Measures of impact included improvements in patients' dispensing profiles, assessed according to predetermined criteria, and decreases in cost and quantity of AUAs dispensed. DESIGN: Controlled study. After evaluation for compliance with predetermined criteria, prescribers identified as having one or two patient profiles with potential errors were assigned alternatively to control or experimental groups. An intervention was mailed to the experimental group. SETTING: Outpatient setting in the New Mexico Medicaid population. PARTICIPANTS: Patients and prescribers identified as having potential misprescribing of AUAs. INTERVENTION: The intervention consisted of a cover letter describing the purpose of the drug utilization review program, an educational fact sheet regarding prescribing AUAs, patient profiles with potential misprescribing, and physician response forms. MEASUREMENTS AND MAIN RESULTS: There were greater improvements in dispensing to patients in the intervention group (chi2, p <.001). Significant odds ratios for the intervention group were 2.29 for AUAs discontinued, 1.98 for all improvements combined, 13.13 for improvement in listing of proper diagnosis for AUAs, and 2.84 for appropriate indication when prescribing the higher acute daily dosage. Using data from 3 months before and after the intervention, we found greater decreases in mean monthly costs (p =.044) and mean monthly quantity of AUAs dispensed (p =.049) in the intervention group. CONCLUSIONS: This intervention significantly decreased AUA dispensing to patients whose prescribers were mailed the patient-specific feedback intervention. (+info)
Audiotapes and letters to patients: the practice and views of oncologists, surgeons and general practitioners.
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A range of measures have been proposed to enhance the provision of information to cancer patients and randomized controlled trials have demonstrated their impact on patient satisfaction and recall. The current study explored the practice and views of oncologists, surgeons and general practitioners (GPs) with regards to providing patients with consultation audiotapes and summary letters. In stage 1, 28 semi-structured interviews with doctors were conducted to provide qualitative data on which to base a questionnaire. In stage 2, 113 medical oncologists, 43 radiation oncologists, 55 surgeons and 108 GPs completed questionnaires. Only one-third of doctors had ever provided patients with a copy of the letter written to the oncologist or referring doctor, and one-quarter had provided a summary letter or tape. The majority of doctors were opposed to such measures; however, a substantial minority were in favour of providing a letter or tape under certain conditions. More surgeons and GPs (> two-thirds) were opposed to specialists providing a consultation audiotape than oncologists (one-third). Gender, years of experience and attitude to patient involvement in decision-making were predictive of doctors' attitudes. The majority of doctors remain opposed to offering patients personalized information aids. However, practice and perspectives appear to be changing. (+info)
Effects of mailed advice on stress reduction among employees in Japan: a randomized controlled trial.
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We conducted a randomized controlled trial (RCT) to examine the effects of mailed advice on reducing psychological distress, blood pressure, serum lipids, and sick leave of workers employed in a manufacturing plant in Japan. Those who indicated higher psychological distress (defined as having GHQ scores of three or greater) in the baseline questionnaire survey (n = 226) were randomly assigned to an intervention group or a control group. Individualized letters were sent to the subjects of the intervention group, informing them of their stress levels and recommending an improvement in daily habits and other behaviors to reduce stress. Eighty-one and 77 subjects in the intervention and control groups, respectively, responded to the one-year follow-up survey. No significant intervention effect was observed for the GHQ scores, blood pressure, serum lipids, or sick leave (p > 0.05). The intervention effect was marginally significant for changes in regular breakfasts and daily alcohol consumption (p = 0.09). The intervention effect was marginally significant for the GHQ scores among those who initially did not eat breakfast regularly (p = 0.06). The study suggests that only sending mailed advice is not an effective measure for worksite stress reduction. Mailed advice which focuses on a particular subgroup (e.g., those who do not eat breakfast regularly) may be more effective. (+info)
Effect of multiple patient reminders in improving diabetic retinopathy screening. A randomized trial.
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OBJECTIVE: To determine whether multiple mailed patient reminders can produce an increase in the rate of diabetic retinal examinations (DRE) over that seen with a single reminder. RESEARCH DESIGN AND METHODS: All diabetic members > or = 18 years who were enrolled in a large network-based health maintenance organization (HMO) in California from August 1996 to July 1997 were identified using claims and pharmacy databases. Members who had no record of DRE in the HMO's claims database were then randomized into two groups. Both groups received mailed educational materials and a reminder to obtain the examination. Their physician groups also received a letter explaining the program, current guidelines for DRE, and a list of their diabetes patients with their DRE status. The single intervention group received no additional reminders. The multiple intervention group received additional reminders at 3, 6, and 9 months after baseline if they continued with no record of service, as determined from the claims database. RESULTS: The study cohort comprised 19,523 diabetic members, which were randomized into single (n = 9,614) and multiple (n = 9,909) intervention groups. There was an increase in monthly DRE rates after the intervention in August 1996 for both intervention groups. After the second reminder was sent to the multiple intervention group, the percentage of diabetic members receiving DRE was higher than the single intervention group. Rates before and after the third intervention were not significantly different, nor were monthly differences found. There was a significant difference in overall annual DRE rates between the groups (P = 0.023). CONCLUSIONS: Multiple patient reminders are more effective than single reminders in improving DRE rates in a managed care setting. However, the improvement noted was clinically small and appeared only after the second reminder; no incremental improvement was seen with additional reminders. Resources used for multiple reminders aimed at diabetic retinopathy might better be spent on other approaches to reducing complications of diabetes. (+info)