Leaving gatekeeping behind--effects of opening access to specialists for adults in a health maintenance organization.
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BACKGROUND: Gatekeeping refers to the prior approval of referrals to specialists by a primary care physician. Although many health plans view gatekeeping as an essential tool for controlling costs and coordinating care, many patients and physicians object to it. METHODS: On April 1, 1998, Harvard Vanguard Medical Associates, a large, multispecialty, capitated group practice previously known as Harvard Community Health Plan, eliminated a gatekeeping system that had been in place for over 25 years. We determined the effects of opening access to specialists on visits to primary care physicians and specialists by adults. In randomly selected cohorts of 10,000 members each, we analyzed visits during 6-month periods for the 3 years before and 18 months after gatekeeping was eliminated. RESULTS: Adults visited a primary care physician an average of 1.21 times and 1.19 times per six-month period before and after the elimination of gatekeeping, respectively (P=0.05); the average number of visits to a specialist was 0.78 per six-month period both before and after its elimination (P=0.35). There was little change in the percentage of visits to specialists included in the analysis as a proportion of all visits (39.1 percent before the elimination of gatekeeping and 39.5 percent afterward). The percentage of first visits to specialists as a proportion of all visits to specialists included in the analysis increased from 24.7 to 28.2 percent (P<0.001). There were small increases in the numbers of visits to orthopedists and physical or occupational therapists. The proportion of visits to specialists for low back pain that were new consultations increased from 26.6 to 32.9 percent (P=0.01). CONCLUSIONS: In a capitated, multispecialty group practice, we found little evidence of substantial changes in the use of specialty services by adults in the first 18 months after the elimination of gatekeeping. (+info)
Effects of ergonomic intervention in work with video display units.
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OBJECTIVES: This study evaluated the effect of an intensive ergonomic approach and education on workstation changes and musculoskeletal disorders among workers who used a video display unit (VDU). METHODS: A randomized controlled design was used. The subjects (N=124) were allocated into three groups (intensive ergonomics, ergonomic education, reference) using stratified random sampling. The evaluation involved questionnaires, a diary of discomfort, measurements of workload, and an ergonomic rating of the workstations. The assessments were made 2 weeks before the intervention and after 2 and 10 months of follow-up. RESULTS: The intensive and training groups showed less musculoskeletal discomfort than the reference group after 2 months of follow-up. Positive effects on discomfort were seen primarily for the shoulder, neck, and upper back areas. No significant differences were found for the strain levels or prevalence of pain. After the intervention the ergonomic level was distinctly higher in the intensive ergonomic group than in the education or reference group. CONCLUSIONS: Both the intensive ergonomics approach and education in ergonomics help reduce discomfort in VDU work. In attempts to improve the physical ergonomics of VDU workstations, the best result will be achieved with cooperative planning in which both workers and practitioners are actively involved. (+info)
Rehabilitation for balance and ambulation in a patient with attention impairment due to intracranial hemorrhage.
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BACKGROUND AND PURPOSE: The purpose of this case report is to describe physical therapy to improve the balance and ambulation of a 16-year-old patient with attention impairment following intracranial hemorrhage. CASE DESCRIPTION: The patient initially had frequent losses of balance, especially in distracting environments, due in part to decreased attention. He was managed with a balance and ambulation training program that incorporated the principles of cognitive rehabilitation for attention impairments. OUTCOMES: Following 11 weeks of outpatient therapy, the patient returned to independent ambulation at school without losses of balance. DISCUSSION: Research is needed to determine the interaction between balance and attention in patients with brain injury and effective treatment for patients with decreased balance related to attention impairments. (+info)
Occupational therapy for accessory nerve palsy after radical neck dissection.
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The subjects in this study were ten patients with accessory nerve palsy after radical neck dissection. All the primary diseases that accounted for radical neck dissection were malignant tumors located at the head or neck. Every patient received occupational therapy and underwent evaluations before and after the therapy. The data we collected included the existence of resting pain and motion pain, and the active and passive range of motion during shoulder flexion and abduction. The occupational therapy programs were not adequately effective for resting and motion pain, however, every patient gained independence for activities of daily living and housekeeping activities. The occupational therapy significantly improved the patient's shoulder elevation in all movements; although, the active abduction was always significantly poor compared with flexion. In the meantime, there were no significant differences between passive shoulder flexion and abduction at all times. We can therefore understand that the accessory nerve palsy especially affects active shoulder abduction induced by the trapezius paralysis. Occupational therapy is an effective treatment for the improvement of shoulder function, however, the occupational therapy has limited effectiveness for coping with the pain. (+info)
Comparison of the psychometric characteristics of the functional independence measure, 5 item Barthel index, and 10 item Barthel index in patients with stroke.
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OBJECTIVES: To compare the reliability, validity, and responsiveness of the motor subscale of the functional independence measure (FIM), the original 10 item Barthel index (BI), and the 5 item short form BI (BI-5) in inpatients with stroke receiving rehabilitation. METHODS: 118 inpatients with stroke at a rehabilitation unit participated in the study. The patients were tested with the FIM motor subscale and original BI at admission to the rehabilitation ward and before discharge from the hospital. The distribution, internal consistency, concurrent validity, and responsiveness of each measure were examined. RESULTS: The BI and FIM motor subscale showed acceptable distribution, high internal consistency (alpha coefficient > or = 0.84), high concurrent validity (Spearman's correlation coefficient, r(s) > or = 0.92, intraclass correlation coefficient (ICC) > or = 0.83), and high responsiveness (standardised response mean > or = 1.2, p < 0.001). The BI-5 exhibited a notable floor effect at admission but this was not found at discharge. The BI-5 showed acceptable internal consistency at admission and discharge (alpha coefficient > or = 0.71). The concurrent validity of the BI-5 was poor to fair at admission (r(s) = 0.74, ICC < or = 0.55) but was good at discharge (r(s) > or = 0.92, ICC > or = 0.74). It is noted that the responsiveness of the BI-5 was as high as that of the BI and the FIM motor subscale. CONCLUSIONS: The results showed that the BI and FIM motor subscale had very acceptable and similar psychometric characteristics. The BI-5 appeared to have limited discriminative ability at admission, particularly for patients with severe disability; otherwise the BI-5 had very adequate psychometric properties. These results may provide information useful in the selection of activities of daily living measures for both clinicians and researchers. (+info)
Culturally based interventions for substance use and child abuse among native Hawaiians.
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OBJECTIVE: This article presents an overview of child abuse among culturally diverse populations in Hawaii, substance use among culturally diverse students in Hawaii, and culturally based interventions for preventing child abuse and substance abuse in Native Hawaiian families. OBSERVATIONS: Native Hawaiians accounted for the largest number of cases of child abuse and neglect in Hawaii between 1996 and 1998. Alcohol and other drugs have increasingly been linked with child maltreatment. Native Hawaiian youths report the highest rate of substance use in Hawaii. Cultural factors such as spirituality, family, and cultural identification and pride are important in interventions with Native Hawaiians. CONCLUSION: Human services should continue to emphasize interventions that integrate "mainstream" and cultural-specific approaches. (+info)
A qualitative study of clinical decision making in recommending discharge placement from the acute care setting.
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BACKGROUND AND PURPOSE: One of the roles of rehabilitation professionals in the acute care setting is making recommendations for patients' discharge placement. The purpose of this investigation was to explore the decision-making process of physical therapists and occupational therapists when recommending discharge destination for patients following acute care hospitalization. SUBJECTS: Participants were 7 physical therapists and 2 occupational therapists in an acute care rotation at a large academic medical center. METHODS: A grounded-theory strategy was used. Three interviews were conducted and guided by questions about participants' approaches to discharge decision making. Information from the interview transcripts was used to define constructs. A model was generated to explain the relationships among the constructs. RESULTS: Decision making regarding discharge recommendations was guided by 4 constructs: patients' functioning and disability, patients' wants and needs, patients' ability to participate in care, and patients' life context. Information was filtered through therapists' experiences and modified by the health care team's opinions and by health care regulations. DISCUSSION AND CONCLUSION: The decision making of the rehabilitation professionals studied in recommending discharge placements for their patients reflects consideration of patients as individuals and the environments in which they live. Information about patients is filtered through the experience of therapists and influenced by health care regulations and opinions of other health care professionals, the patients, and their associates. The findings might be used in teaching clinical decision making to clinicians and students as they learn to make discharge recommendations. (+info)
Occupational therapy for stroke patients: a systematic review.
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BACKGROUND AND PURPOSE: Occupational therapy (OT) is an important aspect of stroke rehabilitation. The objective of this study was to determine from the available literature whether OT interventions improve outcome for stroke patients. METHODS: An extensive search in MEDLINE, CINAHL, EMBASE, AMED, and SCISEARCH was performed. Studies with controlled and uncontrolled designs were included. Seven intervention categories were distinguished and separately analyzed. If a quantitative approach (meta-analysis) of data analysis was not appropriate, a qualitative approach (best-evidence synthesis), based on the type of design, methodological quality, and significant findings of outcome and/or process measures, was performed. RESULTS: Thirty-two studies were included in this review, of which 18 were randomized controlled trials. Ten randomized controlled trials had a high methodological quality. For the comprehensive OT intervention, the pooled standardized mean difference for primary activities of daily living (ADL) (0.46; CI, 0.04 to 0.88), extended ADL (0.32; CI, 0.00 to 0.64), and social participation (0.33; CI, 0.03 to 0.62) favored treatment. For the training of skills intervention, some evidence for improvement in primary ADL was found. Insufficient evidence was found to indicate that the provision of splints is effective in decreasing muscle tone. CONCLUSIONS: This review identified small but significant effect sizes for the efficacy of comprehensive OT on primary ADL, extended ADL, and social participation. These results correspond to the outcome of a systematic review of intensified rehabilitation for stroke patients. The amount of evidence with respect to specific interventions, however, is limited. More research is needed to enable evidence-based OT for stroke patients. (+info)