Providing good quality diabetes care is complex but achievable. Many aspects of the care do not require high tech medicine but, rather, good organisation. Diabetes is a costly disease, consuming 1500 pounds per diabetic patient per year versus 500 pounds on average for a non-diabetic member of the population in health service costs. Investment now in good quality diabetes care is sound: patients will benefit from a better quality of life associated with a reduced incidence of the complications of diabetes and the direct costs to the health service in treating these complications and the indirect costs to employers will be reduced. Physical and clinical assessments--measurements of blood glucose and glycosylated haemoglobin concentrations, weight, and blood pressure and assessment of eyes, kidneys, feet, and heart--are clearly important, but quality must include consideration of people and their reactions to life and diabetes--a lifelong entanglement--for which much more support should be provided. (+info)
Sending parents outpatient letters about their children: parents' and general practitioners' views.
(10/1294)
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)
Feasibility of monitoring patient based health outcomes in a routine hospital setting.
(11/1294)
OBJECTIVE: To assess the feasibility of monitoring health outcomes in a routine hospital setting and the value of feedback of outcomes data to clinicians by using the SF 36 health survey questionnaire. DESIGN: Administration of the questionnaire at baseline and three months, with analysis and interpretation of health status data after adjustments for sociodemographic variables and in conjunction with clinical data. Exploration of usefulness of outcomes data to clinicians through feedback discussion sessions and by an evaluation questionnaire. SETTING: One gastroenterology outpatient department in Aberdeen Royal Hospitals Trust, Scotland. PATIENTS: All (573) patients attending the department during one month (April 1993). MAIN MEASURES: Ability to obtain patient based outcomes data and requisite clinical information and feed it back to the clinicians in a useful and accessible form. RESULTS: Questionnaires were completed by 542 (95%) patients at baseline and 450 (87%) patients at follow up. Baseline health status data and health outcomes data for the eight different aspects of health were analysed for individual patients, key groups of patients, and the total recruited patient population. Significant differences were shown between patients and the general population and between different groups of patients, and in health status over time. After adjustment for differences in sociodemography and main diagnosis patients with particularly poor scores were identified and discussed. Clinicians judged that this type of assessment could be useful for individual patients if the results were available at the time of consultation or for a well defined group of patients if used as part of a clinical trial. CONCLUSIONS: Monitoring routine outcomes is feasible and instruments to achieve this, such as the SF 36 questionnaire, have potential value in an outpatient setting. IMPLICATIONS: If data on outcomes are to provide a basis for clinical and managerial decision making, information systems will be required to collect, analyse, interpret, and feed it back regularly and in good time. (+info)
The fall and rise of cost sharing in Kenya: the impact of phased implementation.
(12/1294)
The combined effects of increasing demand for health services and declining real public resources have recently led many governments in the developing world to explore various health financing alternatives. Faced with a significant decline during the 1980s in its real per capita expenditures, the Kenya Ministry of Health (MOH) introduced a new cost sharing programme in December 1989. The programme was part of a comprehensive health financing strategy which also included social insurance, efficiency measures, and private sector development. Early implementation problems led to the suspension in September 1990 of the outpatient registration fee, the major revenue source at the time. In 1991, the Ministry initiated a programme of management improvement and gradual re-introduction of an outpatient fee, but this time as a treatment fee. The new programme was carried out in phases, beginning at the national and provincial levels and proceeding to the local level. The impact of these changes was assessed with national revenue collection reports, quality of care surveys in 6 purposively selected indicator districts, and time series analysis of monthly utilization in these same districts. In contrast to the significant fall in revenue experienced over the period of the initial programme, the later management improvements and fee adjustments resulted in steady increases in revenue. As a percentage of total non-staff expenditures, fiscal year 1993-1994 revenue is estimated to have been 37% at provincial general hospitals, 20% at smaller hospitals, and 21% at health centres. Roughly one third of total revenue is derived from national insurance claims. Quality of care measures, though in some respects improved with cost sharing, were in general somewhat mixed and inconsistent. The 1989 outpatient registration fee led to an average reduction in utilization of 27% at provincial hospitals, 45% at district hospitals, and 33% at health centres. In contrast, phased introduction of the outpatient treatment fee beginning in 1992, combined with somewhat broader exemptions, was associated with much smaller decreases in outpatient utilization. It is suggested that implementing user fees in phases by level of health facility is important to gain patient acceptance, to develop the requisite management systems, and to orient ministry staff to the new systems. (+info)
Day surgery; development of a questionnaire for eliciting patients' experiences.
(13/1294)
OBJECTIVE: To develop a single, short, acceptable, and validated postal questionnaire for assessing patients' experiences of the process and outcome of day surgery. DESIGN: Interviews and review of existing questionnaires; piloting and field testing of draft questionnaires; consistency and validity checks. SETTING: Four hospitals, in Coventry (two), Swindon, and Milton Keynes. PATIENTS: 373 patients undergoing day surgery in 1990. MAIN MEASURES: Postoperative symptoms, complications, health and functional status, general satisfaction, and satisfaction with specific aspects of care. RESULTS: Response rates of 50% were obtained on field testing draft questionnaires preoperatively and one week and one month after surgery. 28% of initial non-responders replied on receiving a postal reminder, regardless of whether or not a duplicate questionnaire was sent; a second reminder had little impact. Many patients who expressed overall satisfaction with their care were nevertheless dissatisfied with some specific aspects. Outcome and satisfaction were related to three aspects of case mix; patient's age, sex, and type of operative procedure. The final questionnaire produced as a result of this work included 28 questions with precoded answers plus opportunities to provide qualitative comments. Several factors (only one, shorter questionnaire to complete, fewer categories of nonresponders, and administration locally) suggested that a response rate of at least 65% (with one postal reminder) could be expected. CONCLUSION: A validated questionnaire for day surgery was developed, which will be used to establish a national comparative database. (+info)
Using evidence-based techniques to modify anemia screening practice.
(14/1294)
Routine screening of adolescents for iron-deficiency anemia is a widespread but unproven practice. Using evidence-based quality improvement techniques, including literature synthesis and presentation of clinic-specific data, my colleagues and I reevaluated a clinic policy of obtaining complete blood counts to screen for anemia in all new adolescent patients. Medical record review revealed clinically unsuspected anemia in 8 (3.5) of 229 patients screened. All cases were mild, and only two patients received iron therapy. These data, coupled with national recommendations, led to a reversal of the clinic's policy requiring screening of all new patients. One year later, complete blood counts were obtained for only 6% of new patients. (+info)
Postmarketing analysis of lovastatin use in the VA Northern California System of Clinics: a retrospective, computer-based study.
(15/1294)
Prevention of coronary heart disease is a major public health goal. The efficacy of lovastatin in lowering serum cholesterol has been proven in research studies, but its efficacy in practice is unclear. To evaluate our practice patterns and outcome in the Veterans Administration Northern California System of Clinics, we reviewed computer-based records of 203 unselected patients issued lovastatin; 193 (95%) were men, and the average patient age was 66 +/- 9 years. The average daily dose of lovastatin was 24 +/- 10 mg, and average duration of therapy was 22 +/- 11 months. Only 72 patients (35%) were instructed on the prescription to take their medication with the evening meal, and only 59 patients (29%) had seen a dietitian during the observed (1 to 3 years) treatment period. Nevertheless, among the 124 patients with pretreatment lipid data, total serum cholesterol decreased by 18% from 271 +/- 45 to 221 +/- 41 mg/dL (P < 0.001), and low density lipoprotein (LDL)-cholesterol decreased by 23% from 185 +/- 43 to 143 +/- 37 (P < 0.001) mg/dL. High density lipoprotein-cholesterol and triglycerides were unchanged. Of the 168 patients with LDL-cholesterol data during the treatment period, only 74 (44%) achieved an LDL-cholesterol level of less than 130 mg/dL, the minimum goal for a population of older males with a high incidence of other cardiac risk factors. Safety surveillance with liver function testing was performed at least once in 192 patients (95%), but with creatine phosphokinase (CPK) testing in only 123 patients (61%) during the survey period. Enzyme elevations were minor, but occurred at least intermittently in approximately one quarter of patients. Only 5.7% of patients on lovastatin manifested an increase in transaminases on therapy. Due to incomplete baseline data, it is unclear how many patients had elevated CPK as a result of lovastatin. We conclude that: (1) lovastatin is effective in lowering total and LDL-cholesterol in practice, but is often used in dosage insufficient to lower LDL-cholesterol to goal levels; (2) patients are not being adequately educated on dosing schedules; (3) toxicity may be underestimated by infrequent and inconsistent surveillance; and (4) nonpharmacologic therapy is underutilized. (+info)
Episodes of illness and access to care in the inner city: a comparison of HMO and non-HMO populations.
(16/1294)
Using data from a 1974 household survey, accessibility to ambulatory care is compared for residents of an inner-city area (East Baltimore) whose usual source of care is an HMO (the East Baltimore Medical Plan) and residents of the same area with other usual sources of care. Accessibility is measured by the probability of receiving care for an episode of illness. Results from multivariate linear and probit regressions indicate that children using the HMO are more likely to receive care than are children with other usual care sources, but no significant differences in the probability of receiving care are found among adults. Evidence of a substitution of telephone care for in-person care is also found among persons using the HMO. Data from a 1971 household survey of the same area suggest that selectivity is not an important confounding factor in the analysis. (+info)