An assessment of the operation of an external quality assessment (EQA) scheme in histopathology in the South Thames (West) region: 1995-1998.
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AIMS: To describe the design and organisation of a voluntary regional external quality assessment (EQA) scheme in histopathology, and to record the results obtained over a three year period. METHODS: A protocol is presented in which circulation of EQA slides alternated with teaching sessions. Procedures for the choice of suitable cases, evaluation of submitted diagnoses, and feedback of results to participants are described. The use of teaching sessions, complementary to the slide circulations, and dealing with current diagnostic problems is also outlined. RESULTS: Participation rates in the nine slide circulations varied between 66% and 89%, mean 85%. Overall scores were predictably high but 4% of returns, from 10 pathologists, were unsatisfactory. These low scores were typically isolated or intermittent and none of the participants fulfilled agreed criteria for chronic poor performers. CONCLUSIONS: This scheme has been well supported and overall performances have been satisfactory. The design was sufficiently discriminatory to reveal a few low scores which are analysed in detail. Prompt feedback of results to participants with identification of all "incomplete" and "wrong" diagnoses is essential. Involvement of local histopathologists in designing, running, and monitoring such schemes is important. (+info)
General practitioners' continuing education: a review of policies, strategies and effectiveness, and their implications for the future.
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BACKGROUND: The accreditation and provision of continuing education for general practitioners (GPs) is set to change with new proposals from the General Medical Council, the Government, and the Chief Medical Officer. AIM: To review the theories, policies, strategies, and effectiveness in GP continuing education in the past 10 years. METHOD: A systematic review of the literature by computerized and manual searches of relevant journals and books. RESULTS: Educational theory suggests that continuing education (CE) should be work-based and use the learner's experiences. Audit can play an important role in determining performance and needs assessment, but at present is largely a separate activity. Educational and professional support, such as through mentors or co-tutors, has been successfully piloted but awaits larger scale evaluation. Most accredited educational events are still the postgraduate centre lecture, and GP Tutors have a variable role in CE management and provision. Controlled trials of CE strategies suggest effectiveness is enhanced by personal feedback and work prompts. Qualitative studies have demonstrated that education plays only a small part in influencing doctors' behavior. CONCLUSION: Maintaining good clinical practice is on many stakeholders' agendas. A variety of methods may be effective in CE, and larger scale trials or evaluations are needed. (+info)
Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group.
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OBJECTIVE: To assess the effectiveness of a programme to coordinate and support follow up care in general practice after a hospital diagnosis of myocardial infarction or angina. DESIGN: Randomised controlled trial; stratified random allocation of practices to intervention and control groups. SETTING: All 67 practices in Southampton and south west Hampshire, England. SUBJECTS: 597 adult patients (422 with myocardial infarction and 175 with a new diagnosis of angina) who were recruited during hospital admission or attendance at a chest pain clinic between April 1995 and September 1996. INTERVENTION: Programme to coordinate preventive care led by specialist liaison nurses which sought to improve communication between hospital and general practice and to encourage general practice nurses to provide structured follow up. MAIN OUTCOME MEASURES: Serum total cholesterol concentration, blood pressure, distance walked in 6 minutes, confirmed smoking cessation, and body mass index measured at 1 year follow up. RESULTS: Of 559 surviving patients at 1 year, 502 (90%) were followed up. There was no significant difference between the intervention and control groups in smoking (cotinine validated quit rate 19% v 20%), lipid concentrations (serum total cholesterol 5.80 v 5.93 mmol/l), blood pressure (diastolic pressure 84 v 85 mm Hg), or fitness (distance walked in 6 minutes 443 v 433 m). Body mass index was slightly lower in the intervention group (27.4 v 28.2; P=0.08). CONCLUSIONS: Although the programme was effective in promoting follow up in general practice, it did not improve health outcome. Simply coordinating and supporting existing NHS care is insufficient. Ischaemic heart disease is a chronic condition which requires the same systematic approach to secondary prevention applied in other chronic conditions such as diabetes mellitus. (+info)
Community-level HIV intervention in 5 cities: final outcome data from the CDC AIDS Community Demonstration Projects.
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OBJECTIVES: This study evaluated a theory-based community-level intervention to promote progress toward consistent condom and bleach use among selected populations at increased risk for HIV infection in 5 US cities. METHODS: Role-model stories were distributed, along with condoms and bleach, by community members who encouraged behavior change among injection drug users, their female sex partners, sex workers, non-gay-identified men who have sex with men, high-risk youth, and residents in areas with high sexually transmitted disease rates. Over a 3-year period, cross-sectional interviews (n = 15,205) were conducted in 10 intervention and comparison community pairs. Outcomes were measured on a stage-of-change scale. Observed condom carrying and intervention exposure were also measured. RESULTS: At the community level, movement toward consistent condom use with main (P < .05) and nonmain (P < .05) partners, as well as increased condom carrying (P < .0001), was greater in intervention than in comparison communities. At the individual level, respondents recently exposed to the intervention were more likely to carry condoms and to have higher stage-of-change scores for condom and bleach use. CONCLUSIONS: The intervention led to significant communitywide progress toward consistent HIV risk reduction. (+info)
The reach and effectiveness of a national mass media-led smoking cessation campaign in The Netherlands.
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OBJECTIVES: This study examined the reach, effectiveness, and cost-effectiveness of a mass media-led smoking cessation campaign including television shows, a television clinic, a quit line, local group programs, and a comprehensive publicity campaign. METHODS: A random sample of baseline smokers (n = 1338) was interviewed before and after the campaign and at a 10-month follow-up. A nonpretested control group (n = 508) of baseline smokers was incorporated to control for test effects. RESULTS: Most smokers were aware of the campaign, although active participation rates were low. Dose-response relations between exposure and quitting were found. The follow-up point prevalence abstinence rate attributable to the campaign was estimated to be 4.5% after control for test effects and secular trends. The cost per long-term quitter was about $12. CONCLUSIONS: In spite of a massive rise in tobacco promotion expenditures prior to the campaign and the absence of governmental control over the media, the campaign under study may have increased normal cessation rates substantially. (+info)
Decline in cigarette consumption following implementation of a comprehensive tobacco prevention and education program--Oregon, 1996-1998.
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In November 1996, residents of Oregon approved a ballot measure increasing the cigarette tax by 30 cents (to 68 cents per pack). The measure stipulated that 10% of the additional tax revenue be allocated to the Oregon Health Division (OHD) to develop and implement a tobacco-use prevention program. In 1997, OHD created Oregon's Tobacco Prevention and Education Program (TPEP), a comprehensive, community-based program modeled on the successful tobacco-use prevention programs in California and Massachusetts. To assess the effects of the tax increase and TPEP in Oregon, OHD evaluated data on the number of packs of cigarettes taxed before (1993-1996) and after (1997-1998) the ballot initiative and implementation of the program. Oregon's results also were compared with national data. This report summarizes the results of the analysis, which indicate that consumption of cigarettes in Oregon declined substantially after implementation of the excise tax and TPEP and exceeded the national rate of decline. (+info)
Follow-up care in general practice of patients with myocardial infarction or angina pectoris: initial results of the SHIP trial. Southampton Heart Integrated Care Project.
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OBJECTIVE: We aimed to assess the effectiveness of a nurse-led programme to ensure that follow-up care is provided in general practice after hospital diagnosis of myocardial infarction (MI) or angina pectoris. METHODS: We conducted a randomized controlled trial with stratified random allocation of practices to intervention and control groups within all 67 practices in Southampton and South-West Hampshire, England. The subjects were 422 adult patients with a MI and 175 patients with a new diagnosis of angina recruited during hospital admission or chest pain clinic attendance between April 1995 and September 1996. Intervention involved a programme of secondary preventive care led by specialist liaison nurses in which we sought to improve communication between hospital and general practice and to encourage general practice nurses to provide structured follow-up. The main outcome measures were: extent of general practice follow-up; attendance for cardiac rehabilitation; medication prescribed at hospital discharge; self-reported smoking, diet and exercise; and symptoms of chest pain and shortness of breath. Follow-ups of 90.1 % of subjects at 1 month and 80.6% at 4 months were carried out. RESULTS: Median attendance for nurse follow-up in the 4 months following diagnosis was 3 (IQR 2-5) in intervention practices and 0 (IQR 0-1) in control practices; the median number of visits to a doctor was the same in both groups. At hospital discharge, levels of prescribing of preventive medication were low in both intervention and control groups: aspirin 77 versus 74% (P = 0.32), cholesterol lowering agents 9 versus 10% (P = 0.8). Conversely, 1 month after diagnosis, the vast majority of patients in both groups reported healthy lifestyles: 90 versus 84% reported eating healthy food (P = 0.53); 73 versus 67% taking regular exercise (P = 0.13); 89 versus 92% not smoking (P = 0.77). Take up of cardiac rehabilitation was 37% in the intervention group and 22% in the control group (P = 0.001); the median number of sessions attended was also higher (5 versus 3 out of 6). CONCLUSIONS: The intervention of a liaison nurse is effective in ensuring that general practice nurses follow-up patients after hospital discharge. It does not alter the number of follow-up visits made by the patient to the doctor. Levels of prescribing and reported changes in behaviour at hospital discharge indicate that the main tasks facing practice nurses during follow-up are to help patients to sustain changes in behaviour, to encourage doctors to prescribe appropriate medication and to encourage patients to adhere to medication while returning to an active life. These are very different tasks to those traditionally undertaken by practice nurses in relation to primary prevention, where the emphasis has been on identifying risk and motivating change. Assessment of the effectiveness of practice nurses in undertaking these new tasks requires a longer follow-up. (+info)
Challenges in securing access to care for children.
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Congressional approval of Title XXI of the Social Security Act, which created the State Children's Health Insurance Program (CHIP), is a significant public effort to expand health insurance to children. Experience with the Medicaid program suggests that eligibility does not guarantee children's enrollment or their access to needed services. This paper develops an analytic framework and presents potential indicators to evaluate CHIP's performance and its impact on access, defined broadly to include access to health insurance and access to health services. It also presents options for moving beyond minimal monitoring to an evaluation strategy that would help to improve program outcomes. The policy considerations associated with such a strategy are also discussed. (+info)