Effect of acute stroke unit care integrated with care continuum versus conventional treatment: A randomized 1-year study of elderly patients: the Goteborg 70+ Stroke Study.
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BACKGROUND AND PURPOSE: The aim of the study was to compare the effect of conventional treatment with the effect of acute stroke unit care integrated with geriatric stroke unit care continuum. METHODS: A 1-year study was undertaken with 2:1 randomization to stroke unit care or conventional care, with assessment by an independent team. The study was composed of 249 elderly patients (aged >/=70 years) hospitalized for acute stroke, without previous cerebral lesion and without recognized need of care. Main outcome measures were patients at home after 1 year, ability in daily living activities, health-related quality of life score according to questionnaire, death or institutional care, and death or dependence. RESULTS: One hundred two patients (61%) in the stroke unit and 49 patients (59%) in the general ward group were alive and at home after 1 year (95% CI -10% to 16%). There were no significant differences in daily life activities or quality of life. In patients with concomitant cardiac disease, there was a reduction in death or institutional care after 3 months in the stroke unit group compared with the group receiving conventional care (28% versus 49%, respectively; 95% CI -40% to -3%). This effect did not remain after 1 year. Patients seeking care after 24 hours often had mild stroke and lived alone. CONCLUSIONS: There was no effect on the number of patients living at home after 1 year, but after 3 months of stroke unit care, a beneficial effect was found on mortality and the need for institutional care among those with concomitant heart disease. This study involved patients who were considerably older than those investigated in previous randomized studies of acute stroke unit care; thus, these findings will contribute to the specialized register of controlled trials in stroke. (+info)
Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.).
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BACKGROUND AND PURPOSE: Early treatment is a critical determinant of successful intervention in acute stroke. The study was designed to find current patterns of stroke care by determining delays in time from onset of signs or symptoms to arrival at the emergency department and to initial evaluation by physicians and by identifying factors associated with these delays. METHODS: Data were prospectively collected by nurses and physicians from patients, patients' family members, and medical records from 10 hospitals of the Robert Wood Johnson Health System in New Jersey. RESULTS: A total of 553 patients who presented with signs or symptoms of acute stroke were studied. Thirty-two percent of patients arrived at the emergency department within 1.5 hours of stroke onset. Forty-six percent of patients arrived within 3 hours and 61% within 6 hours. Delays in arrival time were significantly associated with sex, race, transportation mode, and history of cardiovascular disease. Patients arriving by ambulance were more likely to present earlier (odds ratio [OR] 3.7 for arrival within 3 hours; OR 4.5 for arrival within 6 hours). Patients arriving by ambulance (OR 2.3 within 15 minutes; OR 1.7 within 30 minutes) and those requiring admission to intensive care units (OR 4.5 within 15 minutes and OR 5.2 within 30 minutes) were examined sooner by physicians. CONCLUSIONS: Despite national efforts to promote prompt stroke evaluation and treatment, significant delays still exist. The lack of improvement throughout the past decade underscores the need for implementation of effective public health programs designed to minimize the time to evaluation and treatment of stroke. (+info)
Patient preferences for laboratory test results notification.
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BACKGROUND: Patients whose test results are abnormal cannot make health behavior changes until the final phase of the laboratory testing process, patient notification, has been completed. Patients whose results are normal are often not notified at all. Few studies have examined the problematic aspects of patient notification, a crucial step in a complex and expensive process. OBJECTIVE: To determine patient preferences for receiving laboratory test results. STUDY DESIGN: Patient survey by telephone. METHODS: Forty-nine patients with hypercholesterolemia who had had a lipoprotein profile performed within the previous 6 months were asked whether or not they had been informed of the test result, how they were informed, how satisfied they were with the process, and how they would prefer to be notified of results. All patients attended a clinic in suburban Detroit. Questions were read from a prepared script. RESULTS: The majority of patients (94%) preferred to receive notification of all test results: both abnormal results accompanied by recommendations for health management changes, and normal results. Preferences for type of notification included mail (59%), phone (16%), office visit (12%), other or multiple response (6%). CONCLUSION: Notification of both normal and abnormal results is of great importance to patients. Further studies are needed to determine what form of notification is most effective and which method is most satisfactory to patients. (+info)
Telephone care as an adjunct to routine medical follow-up. A negative randomized trial.
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CONTEXT: In 1992, a randomized trial at one outpatient clinic demonstrated that making telephone appointments part of routine medical follow-up could save money and reduce hospitalization. OBJECTIVE: To ascertain the effects of telephone care in other clinics. DESIGN: Consenting patients of 20 physicians were randomly assigned to receive telephone care or usual care. SETTING: Veterans Affairs General Medical Clinics in Denver, Colorado, and Sioux Falls, South Dakota. PATIENTS: 512 predominately male elderly veterans (mean age, 68 years) who had a broad range of chronic medical conditions. INTERVENTION: At the intake clinic visit, the recommended revisit interval (e.g., return in 3 months) for telephone care patients was doubled (e.g., return in 6 months) and three intervening telephone appointments were scheduled. Three telephone appointments were also scheduled at all subsequent clinic visits. MAIN OUTCOME MEASURES: Utilization of services and self-reported health status. RESULTS: More than 2000 calls were made during the 2-year study period. Although the revisit interval was longer for telephone care patients after the intake visit (as was expected), it was the same for both telephone care and usual care patients after all subsequent visits, despite the scheduling of three telephone appointments for telephone care patients. The intervention had no effect on self-reported health status, hospital admission, or number of deaths. The intervention also had no effect on the total number of clinic visits, outpatient laboratory tests, or radiologic tests. Telephone care patients had fewer unscheduled visits than did usual care patients (2.0 vs. 2.8 visits/patient; P = 0.01). CONCLUSION: Telephone care had little effect in this study. Instead of providing a way to maintain contact with patients without requiring them to appear in clinic frequently, telephone appointments became simply an additional service. (+info)
Follow-up among women with an abnormal mammogram in an HMO: is it complete, timely, and efficient?
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OBJECTIVE: To describe the extent to which women with seriously abnormal mammograms complete indicated follow-up, the timeliness of this follow-up, and variations in the pattern of use of diagnostic procedures. STUDY DESIGN: Retrospective chart review. PATIENTS AND METHODS: Ninety-two women enrolled in a single urban health maintenance organization (HMO) with an abnormal index mammogram (mass or suspicious calcifications) during 1995 or 1996 were identified by review of all HMO mammography reports. Data were abstracted from medical records concerning all clinical services received over the 11 months after the date of the abnormal mammogram. Procedure costs were estimated based on 1997 Medicare relative-value units. Logistic regression and a multivariate accelerated failure-time model were used to evaluate the association between predictor variables and the occurrence and timing of completion of follow-up. RESULTS: Follow-up was not completed by 31 (34%) of the 92 study women and was delayed beyond 60 days for another 32 (35%). In adjusted analysis, factors associated with completion within 60 days included age less than 50 years and inclusion of a specific follow-up recommendation in the mammogram report. Completion by the end of the study (a minimum of 11 months after the index mammogram) was associated only with the presence of a specific follow-up recommendation. The follow-up process (i.e., the diagnostic procedures used) was highly variable but almost always included surgical evaluation. The average cost among those completing follow-up was about $1900 (in 1997 dollars). CONCLUSIONS: Incomplete follow-up after a potentially seriously abnormal mammogram constitutes an important barrier to breast cancer control efforts in the study HMO, but its explanation remains incompletely understood. The follow-up process itself is highly variable, and improvement in its efficiency and timely completion will require a better understanding of its determinants. (+info)
Percutaneous endoscopic gastrostomies: attitudes of general practitioners and how management may be improved.
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Percutaneous endoscopic gastrostomy (PEG) has replaced surgical gastrostomy in patients requiring long-term enteral nutrition. Increasing numbers of patients are being referred for PEG placement. Concern has been raised about patient selection and subsequent follow-up of these patients in the community. We report the views of Northern Ireland GPs to PEGs and how management may be improved. (+info)
Frequent attenders' consulting patterns with general practitioners.
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BACKGROUND: Despite the growing literature on frequent attendance, little is known about the consulting patterns of frequent attenders with different doctors. To develop appropriate intervention strategies and to improve the clinical care of frequent attenders, a full understanding of these consulting patterns is essential. AIMS: This paper has three aims: to determine whether frequent attenders consult more with some doctors than others; to determine how many different doctors frequent attenders consult with; and to determine whether frequent attenders exhibit greater continuity of care than non-frequent attenders. METHOD: Analysis of a validated dataset of 592,028 consultations made by 61,055 patients from four practices over 41 months. Comparisons between the consulting patterns of the frequent attenders, defined as the most frequently consulting 3% of the population by practice, with non-frequent attenders and the overall practice populations. RESULTS: There was considerable variation in the numbers and proportions of consultations with frequent attenders between individual doctors. Most of the frequent attenders consulted with most or all of the doctors within practices over the timeframe. Frequent attenders exhibited more continuity of care than non-frequent attenders. CONCLUSION: The reasons why some doctors have more consultations with frequent attenders is unclear. Some doctors may actively encourage frequent attendance. While many frequent attenders have clear allegiances to one doctor, many also consult widely with a large number of doctors. The consequences of such behaviour are unknown. These findings have important implications in the development of appropriate interventions for reducing problematic frequent attendance. (+info)
Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP).
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A group from the European Working Party on Quality in Family Practice (EQuiP), working with over 20 European colleges of primary care, has assessed what, in their view, is needed to improve the quality of care at the interface between general practice and specialists. Experiences and ideas from a wide range of people were gathered through focused group discussions. From these it was clear that, for real improvement at the interface of care, changes are needed in the system of care and in the ways that doctors view their roles and their performance. All providers of care need to be able to see the care system from the patients' perspective if they are to help their patients make sense of and benefit from an increasingly complex system. This paper outlines the EQuiP recommendations on how cooperation between general practitioners and specialists might be improved. This includes strategic perspectives and both targets for improvement and methods for teaching, training and development that are all independent of country and health care system. The 10 targets for development identified by the group are: leadership, initial shared care approaches, task division, mutual guidelines, patient perspective, informatics, education, team building, quality monitoring systems, and cost effectiveness. Working towards these targets could provide an effective approach to improving the cooperation between the interfaces of care. Getting effective leadership is a necessary first step as implementation of such a strategy will involve significant change. Responsibility lies primarily with the medical profession. (+info)