Production and evaluation of guidelines for the management of inflammatory bowel disease: the Leicester experience.
(25/2029)
Consensus guidelines for the management of patients with inflammatory bowel disease were produced by gastroenterologists, gastrointestinal surgeons and a cross-section of general practitioners (GPs) from Leicestershire in order to develop a seamless pattern of care with a common approach to diagnosis and treatment. It was hoped that the guidelines would encourage a movement towards care in the community for many patients with stable disease and so speed up new consultation rates. The study then assessed the impact of these guidelines on the referral letters of GPs to hospital consultants, the prediction of disease and adherence to them on re-referring patients after discharge. The guidelines were distributed to all 487 GPs in the Leicester Health Authority area and the gastroenterology teams within the hospitals. The value of the guidelines was assessed by an audit of referral letters, the length of time from referral letter to out-patient appointment, both before and after the launch of the guidelines, adherence to the guidelines on re-referral, and monitoring the outcome of the discharged patients. Whilst the guidelines may have helped GPs to manage stable patients in the community, the content of referral letters and the diagnostic abilities of GPs were not seen to improve since the launch of the guidelines. However, only 5% of stable patients who were discharged from one clinic were re-referred for inflammatory bowel disease. (+info)
The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems.
(26/2029)
OBJECTIVES: The authors examined Americans' opinions about financial and treatment competence of people with mental health problems, potential for harm to self or others, and the use of legal means to force treatment. METHODS: The 1996 General Social Survey provided interview data with a nationally representative sample (n = 1444). Respondents were given a vignette based on diagnostic criteria for schizophrenia, major depression, alcohol dependence, or drug dependence, or a "control" case. RESULTS: The specific nature of the problem was the most important factor shaping public reaction. Respondents viewed those with "troubles," alcohol dependence, or depression as able to make treatment decisions. Most reported that persons with alcohol or drug problems or schizophrenia cannot manage money and are likely to be violent toward others. Respondents indicated a willingness to coerce individuals into treatment. Respondent and other case characteristics rarely affected opinions. CONCLUSIONS: Americans report greater concern with individuals who have drug or alcohol problems than with persons who have other mental health problems. Evaluations of dangerousness and coercion indicate a continuing need for public education. (+info)
Towards a feasible model for shared decision making: focus group study with general practice registrars.
(27/2029)
OBJECTIVES: To explore the views of general practice registrars about involving patients in decisions and to assess the feasibility of using the shared decision making model by means of simulated general practice consultations. DESIGN: Qualitative study based on focus group interviews. SETTING: General practice vocational training schemes in south Wales. PARTICIPANTS: 39 general practice registrars and eight course organisers (acting as observers) attended four sessions; three simulated patients attended each time. METHOD: After an introduction to the principles and suggested stages of shared decision making the registrars conducted and observed a series of consultations about choices of treatment with simulated patients using verbal, numerical, and graphical data formats. Reactions were elicited by using focus group interviews after each consultation and content analysis undertaken. RESULTS: Registrars in general practice report not being trained in the skills required to involve patients in clinical decisions. They had a wide range of opinions about "involving patients in decisions," ranging from protective paternalism ("doctor knows best"), through enlightened self interest (lightening the load), to the potential rewards of a more egalitarian relationship with patients. The work points to three contextual precursors for the process: the availability of reliable information, appropriate timing of the decision making process, and the readiness of patients to accept an active role in their own management. CONCLUSIONS: Sharing decisions entails sharing the uncertainties about the outcomes of medical processes and involves exposing the fact that data are often unavailable or not known; this can cause anxiety to both patient and clinician. Movement towards further patient involvement will depend on both the skills and the attitudes of professionals, and this work shows the steps that need to be taken if further progress is to be made in this direction. (+info)
Chinese and U.S. internists adhere to different ethical standards.
(28/2029)
OBJECTIVE: To determine whether internists in the United States and China have different ideas and behaviors regarding informing patients of terminal diagnoses and HIV/AIDS, the role of the family in end-of-life decision making, and assisted suicide. DESIGN: Structured questionnaire of clinical vignettes followed by multiple choice questions. SETTING: University and community hospitals in San Francisco and Beijing, China. SUBJECTS: Forty practicing internists were interviewed, 20 in China and 20 in the United States. MEASUREMENTS AND MAIN RESULTS: Of the internists surveyed, 95% of the U.S. internists and none of the Chinese internists would inform a patient with cancer of her diagnosis. However, 100% of U.S. and 90% of Chinese internists would tell a terminally ill patient who had AIDS, rather than advanced cancer, about his diagnosis. When family members' wishes conflicted with a patient's preferences regarding chemotherapy of advanced cancer, Chinese internists were more likely to follow the family's preferences rather than the patient's preferences (65%) than were the U.S. internists (5%). Thirty percent of U.S. internists and 15% of Chinese internists agreed with a terminally ill patient's request for sufficient narcotics to end her life. CONCLUSIONS: We found significant differences in clinical ethical beliefs between internists in the United States and China, most evident in informing patients of a cancer diagnosis. In general, the Chinese physicians appeared to give far greater weight to family preferences in medical decision making than did the U.S. physicians. (+info)
Strategic physician communication and oncology clinical trials.
(29/2029)
PURPOSE: Clinical trials are the primary means for determining new, effective treatments for cancer patients, yet the number of patients that accrue is relatively limited. The purpose of this study was to explore the relationship between physician behavior and patient accrual to a clinical trial by videotaping the interaction. PATIENTS AND METHODS: Forty-eight patient-physician interactions involving 12 different oncologists were videotaped in several clinics at the H. Lee Moffitt Cancer Center and Research Institute (Tampa, FL). The purpose of each interaction was to present the possibility of a clinical trial to the patient. A coding system, the Moffitt Accrual Analysis System, was developed by the authors to code behaviors that represented both the legal-informational and social influence models of communication behavior. Thirty-two patients agreed to participate in the clinical trial. RESULTS: Videotaping was found to be a viable, valid, and reliable method for studying the interaction. Physicians who were observed to use both models of influence were found to enroll more patients. Thus, patients were more likely to accrue to the trial when their physician verbally presented items normally included in an informed consent document and when they behaved in a reflective, patient-centered, supportive, and responsive manner. Discussion of benefits, side effects, patient concerns and resources to manage the concerns were all associated with accrual. CONCLUSION: This research has implications for modifying physician behavior and, thus, increasing the numbers of patients accruing to oncology clinical trials. (+info)
Interpersonal processes of care in diverse populations.
(30/2029)
Persons of lower socioeconomic status and members of racial and ethnic minority groups experience poorer health and increased health risk factors. A framework of interpersonal processes of care specifies distinct components and incorporates the perspective of diverse racial and ethnic or socioeconomic groups. Its dimensions, each with several domains, are communication (general clarity, elicitation of and responsiveness to patient concerns, explanations, empowerment), decision making (responsiveness to patient preferences, consideration of ability and desire to comply), and interpersonal style (friendliness, respectfulness, discrimination, cultural sensitivity, support). All the domains, except cultural sensitivity, were validated through a survey of 603 ethnically diverse, low-income adults. Confirmation of the framework's usefulness should enable researchers to explore how interpersonal processes might account for observed ethnic and social class differences in health care and health. (+info)
Self-reported bacterial infections among women with or at risk for human immunodeficiency virus infection.
(31/2029)
Bacterial infections are a major cause of morbidity and mortality in persons with human immunodeficiency virus (HIV) infection, particularly women. We performed a cross-sectional analysis of a history of bacterial infections among 1,310 women with or at risk for HIV infection. HIV-seropositive women were significantly more likely than seronegative women to report recent and lifetime histories of bacterial infection, even after history of injection drug use since 1977 was adjusted for; this included recent pneumonia (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.5-6.6), sinusitis (OR, 1.4; 95% CI, 1.0-2.0), and urinary tract infection (OR, 1.5; 95% CI, 1.1-2.1). Compared with HIV-negative women, women with CD4 cell counts of <200 were about eight times more likely to report recent pneumonia (OR, 7.8; 95% CI, 3.4-17.7); those with CD4 cell counts of 200-500 were almost three times more likely to do so (OR, 2.6; CI, 1.2-5.7). Logistic regression analysis revealed that only CD4 cell category and a recent history of smoking had a significant relationship to self-reported pneumonia. (+info)
Modeling of medical and surgical treatment costs of chronic pelvic pain: new paradigms for making clinical decisions.
(32/2029)
Additional complexity has been added to the healthcare decision-making process by the socioeconomic constraints of the industry and a population that is increasingly educated about healthcare. As a result, decisions balanced on the basis of outcomes and economic realities are needed. This modeling of surgical versus medical treatment costs for chronic pelvic pain and endometriosis factors in the large number of women with chronic pelvic pain, direct and indirect costs of the condition, and clinical benefits, projected costs, and savings of the therapies. This process of calculation becomes an aid for decision making in the current healthcare system. (+info)