Is hospital care involved in inequalities in coronary heart disease mortality? Results from the French WHO-MONICA Project in men aged 30-64.
OBJECTIVES: The goal of the study was to assess whether possible disparities in coronary heart disease (CHD) management between occupational categories (OC) in men might be observed and contribute to the increasing inequalities in CHD morbidity and mortality reported in France. METHODS: The data from the three registers of the French MONICA Collaborative Centres (MCC-Lille, MCC-Strasbourg, and MCC-Toulouse) were analysed during two period: 1985-87 and 1989-91. Acute myocardial infarctions and coronary deaths concerning men, aged 30-64 years, were included. Non-professionally active and retired men were excluded. Results were adjusted for age and MCC, using a logistic regression analysis. RESULTS: 605 and 695 events were analysed for 1985-87 and 1989-91, respectively. Out of hospital cardiac arrests, with or without cardiac resuscitation, and 28 day case fatality rates were lower among upper executives in both periods. A coronarography before the acute event had been performed more frequently in men of this category and the proportion of events that could be hospitalised was higher among them. In both periods, the management of acute myocardial infarctions in hospital and prescriptions on discharge were similar among occupational categories. CONCLUSIONS: For patients who could be admitted to hospital, the management was found to be similar among OCs, as was the 28 day case fatality rate among the hospitalised patients. In contrast, lower prognosis and higher probability of being hospitalised after the event among some categories suggest that pre-hospital care and the patient's conditions before the event are the primary factors involved. (+info)
Management of asthma and COPD patients: feasibility of the application of guidelines in general practice.
OBJECTIVE: To examine the feasibility of the application of guidelines to the management of asthma and chronic obstructive pulmonary disease (COPD) by assessing compliance with the guidelines and listing the barriers general practitioners (GPs) encountered during implementation. Insight into the feasibility of individual items in the guidelines can guide implementation strategies in the future and, if necessary, support revision of the guidelines. DESIGN: Descriptive study of care delivered during the implementation of guidelines by means of documentation of the care provided, education, feedback on compliance and peer review. SETTING: General practice. STUDY PARTICIPANTS: Sixteen GPs in 14 general practices. MAIN OUTCOME MEASURES: Compliance was expressed as the percentage of patients per practice managed by the GPs according to the guidelines. For each patient (n=413) data were collected on the care delivered during the first year of the implementation. Barriers encountered were derived from the summaries of the discussions held during the monthly meetings. RESULTS: The GPs were most compliant on the items 'PEFR measurement at every consultation' (98%), 'allergy test' (78%) and 'advice to stop smoking' (82%), and less compliant on the items 'four or more consultations a year' (46%), 'ordering spirometry' (33%), 'adjustment of medication' (42%), 'check on inhalation technique' (38%) and referral to a chest physician (17%) or a district nurse (5%). The main barriers were the amount of time to be invested, doubts about the necessity of regular consultations and about the indications for ordering spirometry and for referral to a chest physician or a district nurse. CONCLUSION: Although the feasibility was assessed in a fairly optimal situation, compliance with the guidelines was not maximal, and differed between the individual items of care. Suggestions are given for further improvements in compliance with the guidelines and for revision of the guidelines. (+info)
Chronic ambulatory outpatients and four-vector management.
Many psychiatrist and other mental healthcare professionals consider the availability of atypical antipsychotic drugs a welcome advance in the treatment of schizophrenia. Atypical agents have show to be effective against both positive and negative symptoms of schizophrenia, and in general, their efficacy makes patients more responsive to rehabilitation efforts. Although drugs are a cornerstone of treatment, optimal management of chronic ambulatory outpatients with schizophrenia also depends of psychosocial and other approaches. Still, noncompliance needs to be addressed as schizophrenia patients often fail to take their medications for a variety of reasons, including undesirable side effects and lack of insight or denial of having a mental disorder. A four-vector model for optimal management of chronic ambulatory outpatients includes the biological, psychological, social, and spiritual domains. Although the resources for providing comprehensive, forward-looking management are not universally available in many areas of the United States, clinicians should always strive for the ideal. (+info)
Referral centers and specialized care. Based on a presentation by Ronald P. Lesser, MD.
Appropriate diagnosis and treatment and the correct use of specialized services at epilepsy referral centers make it possible to control seizures relatively quickly in a large number of patients. Timeliness is extremely important, however, because delaying treatment decreases the likelihood of achieving complete remission from seizures. Epilepsy has a tremendous impact on quality of life. Concerns about concomitant illnesses, seizure-related injuries, and the psychosocial effects of seizures and anticonvulsants on patients are very real and should be addressed. An accurate diagnosis is the first step in effective seizure control, because not every patient with a seizure disorder has epilepsy. The second step is choosing an antiepileptic drug (AED) that is appropriate for the patient and using the correct dose and dosing schedule. When seizures remain uncontrolled or are poorly controlled despite medical therapy, the patient should be reevaluated to ascertain why the drug or drug combination is not working. The reason may be the wrong diagnosis, the wrong drug, or the wrong dose. If the seizures remain uncontrolled, the patient should be evaluated as a possible candidate for epilepsy surgery. If the patient is a good candidate, a presurgical work-up that includes monitoring and imaging studies should be performed, ideally at an epilepsy referral center. Quality care depends on access, communication, and knowledge, which involves patients who know how to achieve the best possible seizure control, doctors who are well informed and know what to do to ensure that their patients are receiving the best care, and mechanisms that permit consultation among everyone involved in caring for patients with epilepsy. Developing a system of quality, cost-effective care for the management of epilepsy also offers an excellent opportunity to apply such a system to the larger arena of medical care in general. (+info)
Management of inguinal herniae in patients on continuous ambulatory peritoneal dialysis: an audit of current UK practice.
Patients receiving continuous ambulatory peritoneal dialysis are at increased risk for the development of inguinal herniae, with a reported prevalence of 14%. Elective hernia repair is indicated for these patients as strangulation is associated with a high mortality in this population. There are currently no national guidelines relating to the optimal peri-operative management of these patients, in particular the appropriate pre- and post-operative dialysis regimen. The aim of the current study was to evaluate current practice in the UK by means of a postal questionnaire sent to all centres undertaking renal transplantation. Replies were received from 34/37 centres. The principal study finding was the wide variation in surgical practice between different centres with regard to pre- and post-operative dialysis regimes. Only 44% of centres had an established protocol. Based upon the study findings we have devised a protocol that we hope to see implemented into UK practice. Following its introduction, a re-assessment will be performed and the audit cycle completed. (+info)
A comprehensive plan for managed care of patients infected with human immunodeficiency virus.
Medicaid is rapidly moving toward managed care throughout the United States and will have a major impact on care programs for those infected with human immunodeficiency virus (HIV). The experience at the Johns Hopkins HIV Care Service is an example of the transition from fee-for-service to managed care. The Maryland Medicaid program, which has required enrollment of all Medicaid recipients since June 1997, uses an adjusted payment rate and separately funds protease inhibitors. Elements that made the transition to a managed care organization possible included the early development of a comprehensive network of services and a database showing that historical Medicaid payments were low compared with the statewide experience. Our Medicaid managed care program promotes unlimited access to specialists, rejects the "gatekeeper" concept for any service, and includes an open formulary. Nevertheless, it is uncertain that the services now provided can be sustained with anticipated reductions in payments that seem inevitable with Medicaid policies here and nationally. (+info)
Perceptions of house officers who use physician order entry.
OBJECTIVE: Describe the perceptions of housestaff physicians about their experience using computerized physician order entry (POE) in hospitals. METHODS: Qualitative study using data from participant observation, focus groups, and both formal and informal interviews. Data were analyzed by three researchers using a grounded approach to identify patterns and themes in the texts. RESULTS: Six themes were identified, including housestaff education, benefits of POE, problems with POE, feelings about POE, implementation strategies, and the future of POE. CONCLUSION: House officers felt that POE assists patient care but may undermine education. They found that POE works best when tailored to fit local and individual workflow. Implementation strategies should include mechanisms for engaging housestaff in the decision process. (+info)
General-practice-based nurse specialists-taking a lead in improving the care of people with epilepsy.
Epilepsy is almost as common as diabetes and some 750 people with epilepsy die suddenly and prematurely each year. Unfortunately, the management of epilepsy has been much neglected and services often remain fragmented and difficult for patients to understand. We employed a nurse specialist in epilepsy to work with practice nurses in a group of general practices to promote better care, to make patients aware of sources of help and support, and to provide information about issues such as driving, employment and pregnancy. Over 70% of patients with epilepsy attended 'clinics' run by the specialist nurse and many previously unidentified problems were successfully resolved-including misdiagnosis, over-medication and lack of awareness of the side-effects of antiepileptic drugs. Nurse specialists in epilepsy, working with groups of general practices but in collaboration with hospital specialists and voluntary organizations, can take a lead role in facilitating joint working between all those involved in service provision, in training practice nurses and others in the special needs of people with epilepsy and in providing support in hospital clinics. (+info)