Relationship between practice counselling and referral to outpatient psychiatry and clinical psychology.
BACKGROUND: Although reduction in the use of secondary care mental health services is a suggested benefit of counselling in general practice, there has been little empirical investigation of this relationship. AIM: To investigate the relationship between the provision of counselling in general practice and the use of outpatient psychiatry and clinical psychology services across a geographical area. METHOD: Information on referrals to outpatient psychiatry and clinical psychology from all general practices in the London Borough of Islington over one year (October 1993 to September 1994) was collected from the routine information systems of the main hospital departments serving this area. Referral rates per 1000 practice population were compared for practices with and without a practice-based counsellor. RESULTS: Fifteen (35%) of the 43 practices had a counsellor based in the practice. The median referral rate to clinical psychology was higher in practices with a counsellor (4.1 per 1000) than in practices without a counsellor (0.8 per 1000). There was no relationship between the provision of practice counselling and median referral rates to outpatient psychiatry (1.8 per 1000 with a counsellor, 1.7 per 1000 without a counsellor). CONCLUSION: Provision of practice counselling in the study was associated with higher referral rates to clinical psychology and no difference in referral rates to outpatient psychiatry. This is in contrast to the hypothesis that counselling reduces the use of secondary care mental health services. (+info)
'Home hypertension': exploring the inverse white coat response.
BACKGROUND: The classical 'white coat response' to blood pressure measurement has been studied thoroughly. However, little is known about patients showing a reverse pattern, i.e. who have lower blood pressure readings at the clinic than outside healthcare facilities. AIM: To estimate the proportion of patients whose blood pressure levels as determined by self-measurements at home are higher than those taken at the clinic and to explore possible associations with demographic, clinical, and psychological variables. METHOD: Patients consecutively attending (n = 214) an academic family medicine department in Toronto, Canada, were eligible. Subjects aged below 16 years and those on psychotropic or blood pressure-lowering agents were excluded. The clinic-home blood pressure difference (CHBPD) was calculated for each participating subject by subtracting home blood pressure from clinic blood pressure. Those who had negative values were compared with the rest of the sample. RESULTS: A considerable proportion of patients had lower blood pressure at the clinic than at home (systolic, 34.6%; diastolic, 23.8%). These subjects did not differ from the rest of the sample with regard to age, sex, levels of education attained, immigration status, body mass index, experience of current symptoms, blood pressure levels, or psychological distress. However, in patients with a 'negative CHBPD', i.e. lower blood pressure at the clinic than at home, readings taken by an automatic, self-inflating device when still at the clinic were higher than in the rest of the sample. CONCLUSION: The results point to measurement bias being at least partly responsible for higher blood pressure readings outside the clinic. Automatic measurement devices used for self/home blood pressure measurement seem to cause an alerting reaction analogous to the well-described 'white coat response'. (+info)
Development of the physical therapy outpatient satisfaction survey (PTOPS).
BACKGROUND AND PURPOSE: The purposes of this 3-phase study were (1) to identify the underlying components of outpatient satisfaction in physical therapy and (2) to develop a test that would yield reliable and valid measurements of these components. SUBJECTS: Three samples, consisting of 177, 257, and 173 outpatients from 21 facilities, were used in phases 1, 2, and 3, respectively. METHODS AND RESULTS: In phase 1, principal component analyses (PCAs), reliability checks, and correlations with social desirability scales were used to reduce a pool of 98 items to 32 items. These analyses identified a 5-component model of outpatient satisfaction in physical therapy. The phase 2 PCA, with a revised pool of 48 items, indicated that 4 components rather than 5 components represented the best model and resulted in the 34-item Physical Therapy Outpatient Satisfaction Survey (PTOPS). Factor analyses conducted with phase 2 and phase 3 data supported this conclusion and provided evidence for the internal validity of the PTOPS scores. The 4-component scales were labeled "Enhancers," "Detractors," "Location," and "Cost." Responses from subsamples of phase 3 subjects provided evidence for validity of scores in that the PTOPS components of "Enhancers," "Detractors," and "Cost" appeared to differentiate overtly satisfied patients from overtly dissatisfied patients. "Location" and "Enhancer" scores discriminated subjects with excellent attendance at scheduled physical therapy sessions from those with poor attendance. CONCLUSION AND DISCUSSION: In this study, we identified components of outpatient satisfaction in physical therapy and used them to develop a test that would yield valid and reliable measurements of these components. (+info)
Quality circles in ambulatory care: state of development and future perspective in Germany.
OBJECTIVE: To survey the quantitative development of quality circles (peer review groups; QC) and their moderators in ambulatory care in Germany, to describe approaches to documentation and evaluation, to establish what types of facilities and support is available and to assess opinions on the future importance of QC. DESIGN: Cross-sectional survey using a standardized questionnaire and supplementary telephone interviews. SETTING: All 23 German regional Associations of Statutory Health Insurance Physicians (ASHIP) were surveyed. RESULTS: The total number of QC in ambulatory care in Germany increased rapidly from 16 in 1993 to 1633 in June 1996, with about 17% (range 1.0-52.1%) of all practicing physicians (112 158) currently involved. Throughout Germany, 2403 moderators were trained in 168 training courses by the qualifying date. Follow-up meetings were held or being planned in 20 ASHIP, with approximately 39% (23-95%) of the moderators participating. Systematic documentation of QC work was undertaken or planned in all 23 ASHIIP, and 10 ASHIP carried out comparative evaluation, with at least five others planning to start it. The ASHIP promoted the work of QC by providing organizational (22) or financial (20) support, materials (20) or mediation of resource persons (16). Eleven ASHIP received grants from drug companies. ASHIP rated the future importance of QC as increasing (18) or stable (four), but in no case as decreasing. CONCLUSIONS AND RECOMMENDATIONS: The quantitative growth of QC in Germany is encouraging, but the extent of support and evaluation appears insufficient. Increased methodological support and facilitation, follow-up meetings on a more regular basis, improved documentation and evaluation of individual QC, and problem oriented evaluation of their impact on health care are essential for further successful development. Principles, problems and solutions discussed may be relevant for similar QI activities in other countries. (+info)
Neonatal examination and screening trial (NEST): a randomised, controlled, switchback trial of alternative policies for low risk infants.
OBJECTIVE: To evaluate the effectiveness of one rather than two hospital neonatal examinations in detection of abnormalities. DESIGN: Randomised controlled switchback trial. SETTING: Postnatal wards in a teaching hospital in north east Scotland. PARTICIPANTS: All infants delivered at the hospital between March 1993 and February 1995. INTERVENTION: A policy of one neonatal screening examination compared with a policy of two. MAIN OUTCOME MEASURES: Congenital conditions diagnosed in hospital; results of community health assessments at 8 weeks and 8 months; outpatient referrals; inpatient admissions; use of general practioner services; focused analysis of outcomes for suspected hip and heart abnormalities. RESULTS: 4835 babies were allocated to receive one screening examination (one screen policy) and 4877 to receive two (two screen policy). More congenital conditions were suspected at discharge among babies examined twice (9.9 v 8.3 diagnoses per 100 babies; 95% confidence interval for difference 0.3 to 2.7). There was no overall significant difference between the groups in use of community, outpatient, or inpatient resources or in health care received. Although more babies who were examined twice attended orthopaedic outpatient clinics (340 (7%) v 289 (6%)), particularly for suspected congenital dislocation of the hip (176 (3.6/100 babies) v 137 (2.8/100 babies); difference -0.8; -1.5 to 0.1), there was no significant difference in the number of babies who required active management (12 (0.2%) v 15 (0.3%)). CONCLUSIONS: Despite more suspected abnormalities, there was no evidence of net health gain from a policy of two hospital neonatal examinations. Adoption of a single examination policy would save resources both during the postnatal hospital stay and through fewer outpatient consultations. (+info)
Low-molecular-weight heparin in outpatient treatment of DVT.
Patients with a diagnosis of acute deep venous thrombosis have traditionally been hospitalized and treated with unfractionated heparin followed by oral anticoagulation therapy. Several clinical trials have shown that low-molecular-weight heparin is at least as safe and effective as unfractionated heparin in the treatment of uncomplicated deep venous thrombosis. The use of low-molecular-weight heparin in an outpatient program for the management of deep venous thrombosis provides a treatment alternative to hospitalization in selected patients. Use of low-molecular-weight heparin on an outpatient basis requires coordination of care, laboratory monitoring, and patient education and participation in treatment. Overlapping the initiation of warfarin permits long-term anticoagulation. Advantages include a decreased incidence of heparin-induced thrombocytopenia and fewer episodes of bleeding complications. Future clinical trials evaluating the safety and efficacy of low-molecular-weight heparin in the treatment of complicated deep venous thrombosis will further define appropriate indications for use and strategies for outpatient management. (+info)
Retrograde esophageal balloon dilatation for caustic stricture in an outpatient clinic setting.
Caustic injury to the esophagus, with resultant esophageal stricture, is a challenge for the surgeon. These strictures require multiple esophageal dilatations, which are usually performed under general anesthesia and frequently under fluoroscopic control. Because of the risks of multiple general anesthetics and frequent radiation, a technique is described for retrograde esophageal balloon dilatation in an outpatient clinic setting without a general anesthetic or fluoroscopic control. (+info)
Comparison of five methods of malaria detection in the outpatient setting.
In eastern Africa where 90% of the malaria is due to Plasmodium falciparum, the accuracy of malaria diagnosis at the outpatient level is becoming increasingly important due to problems of drug resistance and use of alternative, costly antimalarial drugs. The quantitative buffy coat (QBC) technique, acridine orange staining with an interference filter system, and the ParaSight-F test have been introduced as alternative methods to conventional microscopy for the diagnosis of malaria. Two hundred thirteen outpatients were tested using these alternative methods and conventional microscopy by five experienced technologists; two were randomly allocated to read the results of each test. Paired results showed the highest level of agreement with the ParaSight-F test (99%), followed by Field stain (92%). The results of the QBC technique showed the least agreement (73%). Using conventional microscopy as the reference standard, the ParaSight-F test had a sensitivity range of 90-92% and a specificity of 99%, staining with acridine orange had a sensitivity range of 77-96% and a specificity range of 81-98% and the QBC technique had a sensitivity range of 88-98% and a specificity range of 58-90%. All microscopic tests showed lower sensitivities (as low as 20% using staining with acridine orange) in detecting low parasitemias (< or = 320/microl) than the ParaSight-F test (70%). Due to the high cost of the ParaSight-F test, Field-stained blood films remain the most appropriate method for diagnosis of P. falciparum in eastern Africa. The ParaSight-F test may be used in situations where no trained microscopists are available, or where malaria is strongly suspected and the results of microscopy are negative. (+info)