Referral and consultation in asthma and COPD: an exploration of pulmonologists' views.
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BACKGROUND: The burden of asthma and chronic obstructive pulmonary disease (COPD) on national healthcare systems is expected to increase substantially in future years. Referral guidelines for general practitioners (GPs) and pulmonologists may lead to more efficient use of healthcare facilities. We explored the prevailing views of pulmonologists regarding referral and once-only consultation in asthma and COPD, and compared these views with recently published transmural referral guidelines for GPs and pulmonologists. METHODS: Cross-sectional multiple case study. Twenty-nine Dutch pulmonologists working at non-university hospitals or specialised chest clinics participated in group discussion sessions. RESULTS: The outcome of the discussions and recently published referral guidelines for GPs and pulmonologists showed considerable similarity, but also some marked discrepancies. During the discussions, the main points of disagreement among the pulmonologists were: 1) should GPs or pulmonologists add long-acting beta2-agonists to asthma treatment regimens; 2) should the current cut-off point 'predicted FEV1 <50%' for referral of COPD patients be increased to 60 or 70%; and 3) should an annual exacerbation rate of two episodes a year be used as an undifferentiated referral criterion for COPD patients? For asthma, proposed back-referral (i.e. from pulmonologist to GP) criteria rested on: required dose of inhaled steroids, persistent need for long-acting beta2-agonists, duration of clinical stability and persistence of airway obstruction. Back-referral criteria for COPD rested on age, blood-gas abnormalities and ventilatory limitations. Primary care monitoring facilities and 'shared-care' constructions were considered to be facilitating conditions for back-referral. CONCLUSIONS: This explorative study provided insights into how pulmonologists visualise a rational referral policy for patients with asthma or COPD. These insights can be taken into consideration in future revisions of referral and back-referral guidelines for GPs and pulmonologists. (+info)
Spontaneous pneumothorax: use of aspiration and outcomes of management by respiratory and general physicians.
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BACKGROUND: Spontaneous pneumothorax is a common problem in hospital practice. Despite the publication of guidelines controversy over its initial management still exists, particularly over the use of simple aspiration. METHODS: The management of spontaneous pneumothorax by respiratory and general physicians at our hospital was analysed by retrospective case note review. Eighty five patients were identified over the study period (36 managed by respiratory and 49 by general physicians). RESULTS: There was a significantly greater use of simple aspiration by respiratory (81%) than general physicians (47%, p<0.001) and a higher rate of success in this group. As a result those patients managed by respiratory physicians had fewer intercostal drains inserted and significantly shorter length of stays (mean 5.6 (3.8) days respiratory group and 9.5 (6.8) days in general physicians group, p<0.05). CONCLUSIONS: The greater and more successful use of simple aspiration by respiratory physicians as an initial treatment for spontaneous pneumothorax resulted in improved outcomes and reduced length of hospital stays. (+info)
Moving toward evidence-based practice.
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"Evidence-based practice" involves applying the best available evidence to the care of individuals. Explicit, systematic methods have developed for determining what is the best available evidence. However, often even the highest-level evidence is not thoroughly or effectively used in practice, even if it is widely known. We must rigorously and critically analyze study results to understand their strengths, limitations, and generalizability, and bear in mind that our knowledge will evolve and thereby change our practice. The clinical question is not always how to apply the evidence but whether the available evidence applies to a particular patient. We should always ask whether the right provider is doing the right thing for the right patient at the right time in the right setting with the right resources. (+info)
Measurement of maximal expiratory pressure: effect of holding the lips.
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BACKGROUND: Minor differences in technique may account for the wide range of published normal values of maximum expiratory and inspiratory pressures. The effects of holding the lips while the subject performed a maximal expiratory pressure manoeuvre were investigated in this study. METHODS: Maximum static expiratory pressures (PEmax) obtained with a cylindrical tube by means of lip compression by the subject and technician aided compression were compared in 20 men (mean age 27 years) and 20 women (mean age 28 years). RESULTS: Technician aided lip compression was associated with higher maximum expiratory pressure than compression by the subject in both men (195 v 110 cm H2O) and women (134 v 80 cm H2O). CONCLUSION: Compression of the lips and corners of the mouth should be performed by a trained technician for maximum expiratory pressure measurements when a cylindrical mouthpiece is used. (+info)
Newly diagnosed tuberculosis in inner-city Chicago: the pulmonary fellow perspective.
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BACKGROUND: The extent to which pulmonary fellows encounter patients with newly diagnosed tuberculosis during their 3-year training program in large metropolitan areas in the USA where active tuberculosis is still relatively common is uncertain. OBJECTIVES: To characterize clinical encounters of pulmonary fellows with patients with newly diagnosed tuberculosis at a large university-based training program in inner-city Chicago over a 3-year period. METHODS: A retrospective review of medical records of patients with newly diagnosed tuberculosis at the University of Illinois Medical Center at Chicago outpatient clinics (UMC) and the City of Chicago Department of Public Health Uptown Neighborhood Health Center Tuberculosis Clinic (CDPH) between 1999 and 2001 was conducted. A pulmonary fellow encounter rate (PFER) was derived as the average number of patients with newly diagnosed tuberculosis seen by a pulmonary fellow per month over the 3-year study period in each institution. RESULTS: We found that 9 pulmonary fellows diagnosed, treated and followed all 80 patients with newly diagnosed tuberculosis seen at CDPH over the 3-year study period. By contrast, they evaluated only 14 patients with newly diagnosed tuberculosis and followed 2 of them regularly at UMC (p < 0.05). PFER was 2.96 at CDPH and 0.52 at UMC (p < 0.05). Adverse events ascribed to anti-tuberculosis drugs were observed more frequently in patients seen by pulmonary fellows at CDPH than at UMC (p < 0.05). CONCLUSIONS: Pulmonary fellows are more likely to encounter patients with newly diagnosed tuberculosis at a designated tuberculosis clinic than at a university hospital in inner-city Chicago during their 3-year training. (+info)
A breath of fresh air? Report of the 2003 British Thoracic Society Winter Meeting.
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An overview of some of the key topics presented at the BTS Winter Meeting held in London on 3-5 December 2003. (+info)
Respiratory medical societies and the threat of bioterrorism.
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Respiratory medical societies throughout the world have an important role in helping governments to develop public policy to counter the threat of bioterrorism. (+info)
Respiratory care in the computer age.
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Computerization in health care is rapidly advancing and is improving patient safety (eg, computerized physician order entry decreases the frequency of medical errors) and practitioner effectiveness and efficiency. Computerization and other developing technologies raise concern about the privacy of health information. In 1996 Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which included privacy provisions that went into effect in April 2003. HIPAA has important impacts on health care providers. With the tremendous growth of health care information systems comes the need to standardize the storage and sharing of health information, so there is an initiative underway to develop a National Health Information Infrastructure, which will set standards for health information exchange among consumers, providers, and the public health sector, as well as consolidate the "silos" of health information that are in place today. (+info)