Follow-up care in general practice of patients with myocardial infarction or angina pectoris: initial results of the SHIP trial. Southampton Heart Integrated Care Project.
OBJECTIVE: We aimed to assess the effectiveness of a nurse-led programme to ensure that follow-up care is provided in general practice after hospital diagnosis of myocardial infarction (MI) or angina pectoris. METHODS: We conducted a randomized controlled trial with stratified random allocation of practices to intervention and control groups within all 67 practices in Southampton and South-West Hampshire, England. The subjects were 422 adult patients with a MI and 175 patients with a new diagnosis of angina recruited during hospital admission or chest pain clinic attendance between April 1995 and September 1996. Intervention involved a programme of secondary preventive care led by specialist liaison nurses in which we sought to improve communication between hospital and general practice and to encourage general practice nurses to provide structured follow-up. The main outcome measures were: extent of general practice follow-up; attendance for cardiac rehabilitation; medication prescribed at hospital discharge; self-reported smoking, diet and exercise; and symptoms of chest pain and shortness of breath. Follow-ups of 90.1 % of subjects at 1 month and 80.6% at 4 months were carried out. RESULTS: Median attendance for nurse follow-up in the 4 months following diagnosis was 3 (IQR 2-5) in intervention practices and 0 (IQR 0-1) in control practices; the median number of visits to a doctor was the same in both groups. At hospital discharge, levels of prescribing of preventive medication were low in both intervention and control groups: aspirin 77 versus 74% (P = 0.32), cholesterol lowering agents 9 versus 10% (P = 0.8). Conversely, 1 month after diagnosis, the vast majority of patients in both groups reported healthy lifestyles: 90 versus 84% reported eating healthy food (P = 0.53); 73 versus 67% taking regular exercise (P = 0.13); 89 versus 92% not smoking (P = 0.77). Take up of cardiac rehabilitation was 37% in the intervention group and 22% in the control group (P = 0.001); the median number of sessions attended was also higher (5 versus 3 out of 6). CONCLUSIONS: The intervention of a liaison nurse is effective in ensuring that general practice nurses follow-up patients after hospital discharge. It does not alter the number of follow-up visits made by the patient to the doctor. Levels of prescribing and reported changes in behaviour at hospital discharge indicate that the main tasks facing practice nurses during follow-up are to help patients to sustain changes in behaviour, to encourage doctors to prescribe appropriate medication and to encourage patients to adhere to medication while returning to an active life. These are very different tasks to those traditionally undertaken by practice nurses in relation to primary prevention, where the emphasis has been on identifying risk and motivating change. Assessment of the effectiveness of practice nurses in undertaking these new tasks requires a longer follow-up. (+info)
Follow-up of breast cancer in primary care vs specialist care: results of an economic evaluation.
A randomized controlled trial (RCT) comparing primary-care-centred follow-up of breast cancer patients with the current standard practice of specialist-centred follow-up showed no increase in delay in diagnosing recurrence, and no increase in anxiety or deterioration in health-related quality of life. An economic evaluation of the two schemes of follow-up was conducted concurrent with the RCT Because the RCT found no difference in the primary clinical outcomes, a cost minimization analysis was conducted. Process measures of the quality of care such as frequency and length of visits were superior in primary care. Costs to patients and to the health service were lower in primary care. There was no difference in total costs of diagnostic tests, with particular tests being performed more frequently in primary care than in specialist care. Data are provided on the average frequency and length of visits, and frequency of diagnostic testing for breast cancer patients during the follow-up period. (+info)
Management of primary antibody deficiency by consultant immunologists in the United Kingdom: a paradigm for other rare diseases.
Variation in clinical practice and its effect on outcome is little known for rare diseases such as primary antibody deficiency. As part of a national audit a survey of all 30 consultant immunologists in the United Kingdom dealing with primary antibody deficiency syndromes in adults and children was carried out in 1993 to ascertain their practices in diagnosis and management. Consensus guidelines were published after the survey was completed. Comparison of the survey results of clinical practice at the time the guidelines were published with the standards identified highlighted that the practice of a minority of specialists was at variance with their peers and with the consensus document, particularly in the use of intramuscular immunoglobulin, the dose and frequency of intravenous immunoglobulin, and target trough immunoglobulin G concentration, which has implications for the quality of patient care. However, much closer agreement existed in the key areas of management, such as diagnosis and selection of intravenous immunoglobulin. The approach and the problems identified are relevant to the management of other rare diseases, in which diagnosis and management is complex and there are few specialists with the necessary knowledge to undertake such care. This survey, the first attempted audit of practice, shows that within a motivated group of specialists highly significant differences in practice may exist and the authors emphasise the importance of setting clear guidelines against which care can be assessed. (+info)
Patients' satisfaction with care after stroke: relation with characteristics of patients and care.
OBJECTIVES: To evaluate stroke patients' satisfaction with care received and to identify characteristics of patients and care which are associated with patients' dissatisfaction. DESIGN: Cross sectional study. SETTING: Sample of patients who participated in a multicentre study on quality of care in 23 hospitals in the Netherlands. PATIENTS: 327 non-institutionalised patients who had been in hospital six months before because of stroke. MAIN MEASURES: Data were collected on (a) characteristics of patients: socio-demographic status, cognitive function (mini mental state examination), disability (Barthel index), handicap (Rankin scale), emotional distress (emotional behavior subscale of the sickness impact profile) and health perception; (b) characteristics of care: use of various types of formal care after stroke, unmet care demands perceived by patients, unmet care demands confirmed by their general practitioners, continuity of care, and secondary prevention, and (c) patients' satisfaction with care received. RESULTS: 40% of the study sample were dissatisfied with at least one type of care received. Multivariate analyses showed that unmet care demands perceived by patients (odds ratio (OR) 3.2, 95% confidence interval (95% CI) 1.8-5.7) and emotional distress (OR 1.8, 95% CI 1.1-3.0) were the main variable associated with dissatisfaction. CONCLUSIONS: Patients' satisfaction was primarily associated with emotional distress and unmet care demands perceived by patients. No association was found between patients' satisfaction on the one hand and continuity of care or secondary prevention on the other; two care characteristics that are broadly accepted by professional care givers as important indicators of quality of long term care after stroke. IMPLICATIONS: In view of these findings discussion should take place about the relative weight that should be given to patients' satisfaction as an indicator of quality of care, compared with other quality indicators such as continuity of care and technical competence. More research is needed to find which dimensions of quality care are considered the most important by stroke patients and professional care givers. (+info)
Integrating MCH/FP and STD/HIV services: current debates and future directions.
The issue of integrating MCH/FP and STD/HIV services has gained an increasingly high priority on public health agendas in recent years. In the prevailing climate of health sector reform, policy-makers are likely to be increasingly pressed to address the broader concept of "reproductive health' in the terms consolidated at the Cairo International Conference on Population and Development, and the UN Conference on Women in Beijing. Integrated MCH/FP and STD/HIV services could be regarded as a significant step towards providing integrated reproductive health services, but clarity of issues and concerns is essential. A number of rationales have emerged which argue for the integration of these services, and many concerns have been voiced. There is little consensus, however, on the definition of "integrated services' and there are few documented case studies which might clarify the issues. This paper reviews the context in which rationales for "integrated services' emerged, the issues of concern and the case studies available. It concludes by suggesting future directions for research, noting in particular the need for country-specific and multi-dimensional frameworks and the appropriateness of a policy analysis approach. (+info)
The three dimensions of managed care pharmacy practice.
Our goal is to provide a framework for pharmacy in an evolving healthcare marketplace by identifying and discussing the three dimensions of pharmacy practice: (1) pharmacy practice across the continuum of care; (2) the major elements of pharmacy practice; and (3) the evolution of pharmacy during the five stages of the development of managed care. The framework was devised under the proposition that there is a substantial consistency in what patients need or should expect from pharmacists. As integrated health systems develop, pharmacists must apply their skills and knowledge across the continuum of care to ensure that they play an integral part in the systems. In a managed care environment characterized by change and the development of integrated health systems, pharmacists have opportunities to become involved directly in patient care in such areas as disease prevention, home healthcare, primary care, and subacute care. Information systems, hospital drug distribution, clinical pharmacy, and the fiscal environment comprise the major elements of pharmacy practice within an integrated health system, and the way in which each of these elements evolves as the healthcare market adapts to managed care is critical to pharmacy practice. If the pharmacy profession can demonstrate its ability to manage disease and health, improve outcomes, and reduce costs within the evolving healthcare system, pharmacists will play a vital role in the managed healthcare market in the approaching new millennium. (+info)
Development of a heart failure center: a medical center and cardiology practice join forces to improve care and reduce costs .
Congestive heart failure (CHF) is a rapidly growing and expensive cardiovascular disorder. Conventional care for CHF is ineffective and results in a cycle of "crisis management" that includes repeated emergency department visits, hospitalizations, and physician visits. Recently, a number of outpatient coronary care centers that provide consistent, aggressive outpatient therapies and extensive patient education have emerged and are successfully breaking this cycle of dependence on hospital services. One such effort is the Heart Institute's Heart Failure Center, the result of a partnership between a private-practice cardiology group and our tertiary-care medical center. Our program includes not only patient education and outpatient infusions of inotropic agents, but an electronic linkage to the emergency department and home healthcare services. Preliminary data show that 16 months after the program was initiated, hospital admissions decreased by 30%, hospital days by 42% and average length of stay by 17%. An effective outpatient heart failure program can alleviate the economic burden of CHF and improve the quality of patient care. (+info)
Physicians in training as quality managers: survival strategy for academic health centers.
Being responsible for medical education places academic health centers at a disadvantage in competing for managed care contracts. Although many suggestions have been made for changing medical education to produce physicians who are better prepared for the managed care environment, few studies have shown how physicians in training can actually contribute to the competitiveness of an academic health center. We present three examples of engaging trainees in projects with a population-based perspective that demonstrate how quality improvement for the academic health center can be operationalized and even led by physicians in training. In addition to gaining experience in a managed care skill that is increasingly important for future employment, physicians in training can simultaneously improve the quality of care delivered through the academic health center. (+info)