Quality of life and effectiveness of diabetes care in three different settings in Leuven.
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BACKGROUND: The new diabetes protocol, formulated in Belgium as a consensus between the National Institution of Health Insurance and diabetologists, implicitly assumes the care of type 1 diabetic patients to be more efficient at the specialist level (SP) in hospital, although GPs frequently are involved in diabetes care. OBJECTIVES: A study was carried out in order to highlight differences in diabetes care between three different treatment settings (SP alone, combined SP-GP and GP alone) METHODS: Out of a group of known diabetics, 325 patients were selected according to a stratified cluster sampling technique, in such a way that the three types of diabetes (formerly called type 1, type 2a and type 2b) occurred sufficiently in the three above-defined treatment settings. Outcome data on co-morbidity and diabetes health profile as well as output data on laboratory results were collected for each patient and compared between the different subgroups. RESULTS: On the basis of a response rate of 47.9%, equally distributed over the different levels, we demonstrated that GPs and SPs score equally low on the different measures and that a better follow-up is indicated in all settings. CONCLUSION: Diabetes care in Flanders can be upgraded significantly. There is no evidence that specialists are performing better. Therefore, one could argue for better follow-up of diabetes care in a primary health care setting. (+info)
Nuclear pharmacy, Part I: Emergence of the specialty of nuclear pharmacy.
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OBJECTIVE: Nuclear pharmacy was the first formally recognized area in pharmacy designated as a specialty practice. The events leading to nuclear pharmacy specialty recognition are described in this article. After reading this article the nuclear medicine technologist or nuclear pharmacist should be able to: (a) describe the status of nuclear pharmacy before recognition as a specialty practice; (b) describe the events that stimulated pharmacists to organize a professional unit to meet the needs of nuclear pharmacists; and (c) identify the steps by which nuclear pharmacists become board certified in nuclear pharmacy. (+info)
Unlinked anonymous HIV study of hospital patients and general practice attenders in Glasgow, 1991-1997.
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AIM: To determine whether HIV is spreading from injecting drug users and homosexual/bisexual males into lower risk heterosexual populations in Glasgow, Scotland, and to pilot a method of monitoring HIV prevalence which involves testing routine biochemistry specimens. METHODS: An unlinked anonymous HIV testing study of hospital patients and general practice attenders was conducted during January 1992 to December 1997. Testing was performed on routine biochemistry specimens from patients aged 16-49 years attending two hospitals with catchment areas covering the north and the east of the city. RESULTS: 78,260 specimens were tested in the study period and no patient objected to their samples being tested anonymously. HIV prevalence rates among male and female subjects were 0.63% and 0.01%, respectively; the large difference in prevalence resulted, in part, from the inclusion of HIV infected haemophiliac patients who attended one of the hospitals. Prevalence among male general practice patients ranged between 0.1% and 0.2%, while that for male patients attending surgical or surgically related specialties was 0.1%. CONCLUSIONS: The prevalence data indicate that HIV has not seeded from the high risk groups into the wider heterosexual population, and that the risk of a surgeon acquiring HIV occupationally is extremely low in a city which has an HIV prevalence similar to or greater than that seen in most other parts of the United Kingdom. Large numbers of residual specimens from busy biochemistry laboratories can be processed for unlinked anonymous testing without interfering with the laboratories' routine functions. This survey approach might be best suited to monitoring HIV trends in developing countries with relatively high prevalence rates and where transmission is principally heterosexual. (+info)
Utilization of specialty mental health care among persons with severe mental illness: the roles of demographics, need, insurance, and risk.
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OBJECTIVE: To examine the sociodemographic, need, risk, and insurance characteristics of persons with severe mental illness and the importance of these characteristics for predicting specialty mental health utilization among this group. DATA SOURCE: The Healthcare for Communities survey, a national study that tracks alcohol, drug, and mental health services utilization. Data come from a telephone survey of adults from 60 communities across the United States, and from a supplemental geographically dispersed sample. STUDY DESIGN: Respondents were categorized as having a severe mental disorder, other mental disorder, or no measured mental disorder. Differences among groups in sociodemographics (gender, marital status, race, education, and income), insurance coverage, need for mental health care (symptoms and perceived need), and risk indicators (suicide ideation, criminal involvement, and aggressive behavior) are examined. Measures of service use for mental health care include emergency room, inpatient, and specialty outpatient care. The importance of sociodemographics, need, insurance status, and risk indicators for specialty mental health care utilization are examined through logistic regression. PRINCIPAL FINDINGS: The severely mentally ill in this study are disproportionately African American, unmarried, male, less educated, and have lower family incomes than those with other disorders and those with no measured mental disorders. In a 12-month period almost three-fifths of persons with severe mental illness did not receive specialty mental health care. One in five persons with severe mental illness are uninsured, and Medicare or Medicaid insures 37 percent. Persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured are. Involvement in the criminal justice system also increases the probability that a person will receive care by a factor of about four, independent of level of need. The average number of outpatient visits for specialty care varies little across type of disorder, and the median number of visits (ten) is equivalent for those with a severe mental illness and those with other disorders. CONCLUSIONS: Persons with severe mental illness have a high level of economic and social disadvantage. Barriers to care, including lack of insurance, are substantial and many do not receive specialty care. Public insurance programs are the major points of leverage for improving access, and policy interventions should be targeted to these programs. Problems of adequate care for the severely mentally ill may be exacerbated by the managed care trend to reductions in intensity of treatment. (+info)
Is hospitalism new? An analysis of medicare data from Washington State in 1994.
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CONTEXT: Managed care, increased disease severity, and more complex treatment options may be reasons for the recent enthusiasm for "hospitalists"--physicians who specialize in the care of inpatients. It is not clear, however, whether hospitalism is a new model for caring for inpatients or merely a new description for previously existing practice patterns. PRACTICE PATTERNS EXAMINED: The proportion of physician visits occurring in the hospital before the introduction of the term hospitalists. Five specialties were examined: family/general practice, general internal medicine, cardiology, gastroenterology, and pulmonology. DATA SOURCE: 1994 Medicare Part B claims data for beneficiaries 65 years of age and older who received all of their care in Washington State. RESULTS: For the average family/general practitioner, 10% of all Medicare visits occurred in the hospital. Corresponding figures for the other specialties were 20% for general internists, 36% for cardiologists, 38% for gastroenterologists, and 45% for pulmonologists. A substantial number of physicians devoted most of their Medicare effort to inpatient care (i.e., hospital visits > 50% of total visits). If this definition were used as a proxy for hospitalism, 4% of family/general practitioners, 10% of general internists, 20% of gastroenterologists, 29% of cardiologists, and 37% of pulmonologists would have been considered hospitalists in Washington State during 1994. On the other hand, 35% of family/general practitioners, 18% of general internists, 7% of both gastroenterologists and pulmonologists, and 4% of cardiologists did not bill Medicare for any inpatient visits and could reasonably be categorized as "officists." CONCLUSION: Physicians vary considerably in the proportion of their workload that occurs in the hospital or outpatient setting. Even before the term was coined, a considerable number of physicians were de facto "hospitalists." (+info)
Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care.
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PURPOSE: To conduct a comprehensive review of the health services literature to search for evidence that hospital or physician volume or specialty affects the outcome of cancer care. METHODS: We reviewed the 1988 to 1999 MEDLINE literature that considered the hypothesis that higher volume or specialization equals better outcome in processes or outcomes of cancer treatments. RESULTS: An extensive, consistent literature that supported a volume-outcome relationship was found for cancers treated with technologically complex surgical procedures, eg, most intra-abdominal and lung cancers. These studies predominantly measured in-hospital or 30-day mortality and used the hospital as the unit of analysis. For cancer primarily treated with low-risk surgery, there were fewer studies. An association with hospital and surgeon volume in colon cancer varied with the volume threshold. For breast cancer, British studies found that physician specialty and volume were associated with improved long-term outcomes, and the single American report showed an association between hospital volume of initial surgery and better 5-year survival. Studies of nonsurgical cancers, principally lymphomas and testicular cancer, were few but consistently showed better long-term outcomes associated with larger hospital volume or specialty focus. Studies in recurrent or metastatic cancer were absent. Across studies, the absolute benefit from care at high-volume centers exceeds the benefit from break-through treatments. CONCLUSION: Although these reports are all retrospective, rely on registries with dated data, rarely have predefined hypotheses, and may have publication and self-interest biases, most support a positive volume-outcome relationship in initial cancer treatment. Given the public fear of cancer, its well-defined first identification, and the tumor-node-metastasis taxonomy, actual cancer care should and can be prospectively measured, assessed, and benchmarked. The literature suggests that, for all forms of cancer, efforts to concentrate its initial care would be appropriate. (+info)
A detailed analysis of theatre training activity in a UK teaching hospital.
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We examined the placement of anaesthetists in our department over a 2 yr period. Data were collected from an in-theatre system to provide details of caseload and supervision for 34,856 operations. There was wide variation between anaesthetic sub-specialties with overall supervision levels of 35% of cases for senior house officers (SHOs) and 32% for specialist registrars (SpRs). The consultant data showed the size and areas of teaching reserve in the department. We then examined individual logbooks in order to validate our data, and departmental rotas to put these data into perspective with previous attempts to quantify trainee supervision. Supervision data derived from the rota allocations showed that 86% of SHO lists and 62% of SpR lists were scheduled to be supervised. This study has described our training activity and facilitated departmental changes, as well as highlighting the need for great care in interpreting trainee supervision data acquired from different sources, particularly when comparisons are being made. (+info)
Is the emergency readmission rate a valid outcome indicator?
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OBJECTIVES: The principal aim was to determine whether the emergency readmission rate varies between medical specialties, and to identify whether differences in emergency readmission rates between hospital trusts can be reduced by standardising for specialty. Possible factors influencing emergency readmission were also investigated, including frequency of previous admission and cause of readmission. DESIGN: Emergency readmission rates were obtained from the Scottish Morbidity Record scheme (SMR1) using record linkage, standardised for age and sex. Rates throughout Scotland were analysed by specialty, and rates for general medicine compared among teaching hospital trusts. Cause of emergency readmission was determined from hospital records in a random sample (177 patients). SETTING: Medical specialties throughout Scotland. SUBJECTS: All patients readmitted as an emergency within 28 days of discharge (October 1990 to September 1994). RESULTS: Emergency readmissions varied markedly between medical specialties, with highest rates in nephrology (24.2%, 95% CI 23.5 to 24.8) and haematology (20.4%, 95% CI 19.9 to 20.9), and the lowest in homeopathy (2.2%, 95% CI 1.6 to 2.7) and metabolic diseases (3.5%, 95% CI 2.4 to 4.5). The largest number of emergency readmissions was in general medicine, accounting for 63% of the total. Restricting emergency readmission rates to general medicine significantly altered previous rates. In the year preceding the emergency readmission, 59% of all patients had been admitted to hospital at least once, and most emergency readmissions (73.3%) resulted from a chronic underlying condition. CONCLUSIONS: Significant variations in emergency readmission rates occurred between medical specialties, suggesting that differences between hospital trusts are influenced by differences in specialties and thus case mix. The majority of emergency readmissions occurred in patients with an underlying chronic condition, and many had a history of multiple previous hospital admissions. The emergency readmission rate is therefore unlikely to be a valid outcome indicator reflecting quality of care until routine data are available for standardisation by case mix. (+info)