Showing papers on "Health care published in 1995"

Effective physician-patient communication and health outcomes: a review

Abstract: OBJECTIVE: To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes. DATA SOURCES: The MEDLINE database was searched for articles published from 1983 to 1993 using "physician-patient relations" as the primary medical subject heading. Several bibliographies and conference proceedings were also reviewed. STUDY SELECTION: Randomized controlled trials (RCTs) and analytic studies of physician-patient communication in which patient health was an outcome variable. DATA EXTRACTION: The following information was recorded about each study: sample size, patient characteristics, clinical setting, elements of communication assessed, patient outcomes measured, and direction and significance of any association found between aspects of communication and patient outcomes. DATA SYNTHESIS: Of the 21 studies that met the final criteria for review, 16 reported positive results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control. CONCLUSIONS: Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs. Future research should focus on evaluating such educational programs.

Linking clinical variables with health-related quality of life. A conceptual model of patient outcomes

Abstract: HEALTH-related quality of life (HRQL) is increasingly used as an outcome in clinical trials, effectiveness research, and research on quality of care. Factors that have facilitated this increased usage include the accumulating evidence that measures of HRQL are valid and "reliable,"1the publication of several large clinical trials showing that these outcome measures are responsive to important clinical changes,2-5and the successful development and testing of shorter instruments that are easier to understand and administer.6-13Because these measures describe or characterize what the patient has experienced as the result of medical care, they are useful and important supplements to traditional physiological or biological measures of health status. Given this improved ability to assess patients' health status, how can physicians and health care systems intervene to improve HRQL? Implicit in the use of measures of HRQL in clinical trials and in effectiveness research is the concept that clinical

Changing Physician Performance: A Systematic Review of the Effect of Continuing Medical Education Strategies

Abstract: Objective. —To review the literature relating to the effectiveness of education strategies designed to change physician performance and health care outcomes. Data Sources. —We searched MEDLINE, ERIC, NTIS, the Research and Development Resource Base in Continuing Medical Education, and other relevant data sources from 1975 to 1994, using continuing medical education (CME) and related terms as keywords. We manually searched journals and the bibliographies of other review articles and called on the opinions of recognized experts. Study Selection. —We reviewed studies that met the following criteria: randomized controlled trials of education strategies or interventions that objectively assessed physician performance and/or health care outcomes. These intervention strategies included (alone and in combination) educational materials, formal CME activities, outreach visits such as academic detailing, opinion leaders, patient-mediated strategies, audit with feedback, and reminders. Studies were selected only if more than 50% of the subjects were either practicing physicians or medical residents. Data Extraction. —We extracted the specialty of the physicians targeted by the interventions and the clinical domain and setting of the trial. We also determined the details of the educational intervention, the extent to which needs or barriers to change had been ascertained prior to the intervention, and the main outcome measure(s). Data Synthesis. —We found 99 trials, containing 160 interventions, that met our criteria. Almost two thirds of the interventions (101 of 160) displayed an improvement in at least one major outcome measure: 70% demonstrated a change in physician performance, and 48% of interventions aimed at health care outcomes produced a positive change. Effective change strategies included reminders, patient-mediated interventions, outreach visits, opinion leaders, and multifaceted activities. Audit with feedback and educational materials were less effective, and formal CME conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact. Conclusion. —Widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers. ( JAMA . 1995;274:700-705)

Qualitative Research Methods for Health Professionals

Abstract: The Purpose of Qualitative Research Qualitative Approaches An Overview Principles of Conceptualizing a Qualitative Project Principles of Doing Research Principles of Data Collection Principles of Data Analysis Qualitative Approaches Reporting Qualitative Research

Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research.

Abstract: Qualitative research methods have a long history in the social sciences and deserve to be an essential component in health and health services research. Qualitative and quantitative approaches to research tend to be portrayed as antithetical; the aim of this series of papers is to show the value of a range of qualitative techniques and how they can complement quantitative research. Medical advances, increasing specialisation, rising patient expectations, and the sheer size and diversity of health service provision mean that today's health professionals work in an increasingly complex arena. The wide range of research questions generated by this complexity has encouraged the search for new ways of conducting research. The rapid expansion of research on and about health and health services, and the relatively recent demarcation of a distinct field of “health services research” depend heavily on doctors and other health professionals being investigators, participants, and peer reviewers. Yet some of the most important questions in health services concern the organisation and culture of those who provide health care, such as why the findings of randomised controlled trials are often difficult to apply in day to day clinical practice. The social science methods appropriate to studying such phenomena are very different from the methods familiar to many health professionals. Although the more qualitative approaches found in certain of the social sciences may seem alien alongside the experimental, quantitative methods used in clinical and biomedical research, they should be an essential component of health services research--not just because they enable us to access areas not amenable to quantitative research, such as lay and professional health beliefs, but also because qualitative description is a prerequisite of good quantitative research, particularly in areas that have received little previous investigation. A good example of this is the study of the social consequences of the …

The Quality in Australian Health Care Study

Abstract: A review of the medical records of over 14,000 admissions to 28 hospitals in New South Wales and South Australia revealed that 16.6% of these admissions were associated with an "adverse event", which resulted in disability or a longer hospital stay for the patient and was caused by health care management; 51% of the adverse events were considered preventable. In 77.1% the disability had resolved within 12 months, but in 13.7% the disability was permanent and in 4.9% the patient died.

No magic bullets: a systematic review of 102 trials of interventions to improve professional practice

Abstract: OBJECTIVE: To determine the effectiveness of different types of interventions in improving health professional performance and health outcomes. DATA SOURCES: MEDLINE, SCISEARCH, CINAHL and the Research and Development Resource Base in CME were searched for trials of educational interventions in the health care professions published between 1970 and 1993 inclusive. STUDY SELECTION: Studies were selected if they provided objective measurements of health professional performance or health outcomes and employed random or quasi-random allocation methods in their study designs to assign individual subjects or groups. Interventions included such activities as conferences, outreach visits, the use of local opinion leaders, audit and feedback, and reminder systems. DATA EXTRACTION: Details extracted from the studies included the study design; the unit of allocation (e.g., patient, provider, practice, hospital); the characteristics of the targeted health care professionals, educational interventions and patients (when appropriate); and the main outcome measure. DATA SYNTHESIS: The inclusion criteria were met by 102 trials. Areas of behaviour change included general patient management, preventive services, prescribing practices, treatment of specific conditions such as hypertension or diabetes, and diagnostic service or hospital utilization. Dissemination-only strategies, such as conferences or the mailing of unsolicited materials, demonstrated little or no changes in health professional behaviour or health outcome when used alone. More complex interventions, such as the use of outreach visits or local opinion leaders, ranged from ineffective to highly effective but were most often moderately effective (resulting in reductions of 20% to 50% in the incidence of inappropriate performance). CONCLUSION: There are no "magic bullets" for improving the quality of health care, but there are a wide range of interventions available that, if used appropriately, could lead to important improvements in professional practice and patient outcomes.

Individual-patient monitoring in clinical practice: are available health status surveys adequate?

Abstract: Interest has increased in recent years in incorporating health status measures into clinical practice for use at the individual-patient level. We propose six measurement standards for individual-patient applications: (1) practical features, (2) breadth of health measured, (3) depth of health measured, (4) precision for cross-sectional assessment, (5) precision for longitudinal monitoring and (6) validity. We evaluate five health status surveys (Functional Status Questionnaire, Dartmouth COOP Poster Charts, Nottingham Health Profile, Duke Health Profile, and SF-36 Health Survey) that have been proposed for use in clinical practice. We conducted an analytical literature review to evaluate the six measurement standards for individual-patient applications across the five surveys. The most problematic feature of the five surveys was their lack of precision for individual-patient applications. Across all scales, reliability standards for individual assessment and monitoring were not satisfied, and the 95% Cls were very wide. There was little evidence of the validity of the five surveys for screening, diagnosing, or monitoring individual patients. The health status surveys examined in this paper may not be suitable for monitoring the health and treatment status of individual patients. Clinical usefulness of existing measures might be demonstrated as clinical experience is broadened. At this time, however, it seems that new instruments, or adaptation of existing measures and scaling methods, are needed for individual-patient assessment and monitoring.

Psychiatric and Physical Morbidity Effects of Dementia Caregiving: Prevalence, Correlates, and Causes

Abstract: The dementia caregiving literature is reviewed with the goals of (a) assessing the prevalence and magnitude of psychiatric and physical morbidity effects among caregivers, (b) identifying individual and contextual correlates of reported health effects and their underlying causes, and (c) examining the policy relevance of observed findings. Virtually all studies report elevated levels of depressive symptomatology among caregivers, and those using diagnostic interviews report high rates of clinical depression and anxiety. The evidence is more equivocal and generally weaker for the association between caregiving and physical morbidity, such as self-rated health, number of illnesses, symptomatology, health care utilization, preventive health behaviors, and cardiovascular functioning. Across studies, psychiatric morbidity in caregivers was linked to patient problem behaviors, income, self-rated health, perceived stress, and life satisfaction. Physical morbidity was associated with patient problem behaviors and cognitive impairment, and with caregiver depression, anxiety, and perceived social support. Possible causes of reported effects and policy implications are discussed.

Patient-Centered Medicine: Transforming the Clinical Method

Abstract: Preface. About the authors. List of contributors. Acknowledgments. Part one: overview. Introduction. The evolution of clinical method. Part two: the four components of the patient-centered clinical method. Introduction. The first component: exploring health, disease and the illness experience. 'I don't want to die': case illustrating component 1. 'I should write a letter to the editor!': case illustrating component. The second component: understanding the whole person. Part 1: individual and family. Trauma, tragedy, trust and triumph: case illustrating component 2. The second component: understanding the whole person. Part 2: context. Mary T: case illustrating component 2. 'Doctor, I need you to give me a test to check if I am a lesbian': case illustrating component 2. The third component: finding common ground. 'I'd sooner take my chances!': case illustrating component 3. The fourth component: enhancing the patient-clinician relationship. When we first saw eye to eye: case illustrating component 4. The flag for undefined pain: case illustrating component 4. Part 3: learning and teaching the patient-centered clinical method. Introduction. Becoming a physician: the human experience of medical education. A messenger: case illustrating becoming a physician. Learner-centered teaching. Being there: case illustrating being learner-centered. Challenges in learning and teaching the patient-centered clinical method. Teaching the patient-centered clinical method - practical tips. The case report as a teaching tool for patient-centered care. Margaret L: case illustrating a patient-centered case report. Part 4: the health care context and patient-centered care. Introduction. Team-centered approach: how to build and sustain a team. The team was the container for her story: case illustrating a team-centered approach. Health care costs and patient-centered care. Part 5: research on patient-centered care. Introduction. Using qualitative methodologies to illuminate patient-centered care. Evidence on the impact of patient-centered care. Measuring patient perceptions of patient-centeredness. Measuring patient-centeredness. Conclusions. References. Index.

Evidence based medicine: an approach to clinical problem-solving

Abstract: Doctors within the NHS are confronting major changes at work. While we endeavour to improve the quality of health care, junior doctors' hours have been reduced and the emphasis on continuing medical education has increased. We are confronted by a growing body of information, much of it invalid or irrelevant to clinical practice. This article discusses evidence based medicine, a process of turning clinical problems into questions and then systematically locating, appraising, and using contemporaneous research findings as the basis for clinical decisions. The computerisation of bibliographies and the development of software that permits the rapid location of relevant evidence have made it easier for busy clinicians to make best use of the published literature. Critical appraisal can be used to determine the validity and applicability of the evidence, which is then used to inform clinical decisions. Evidence based medicine can be taught to, and practised by, clinicians at all levels of seniority and can be used to close the gulf between good clinical research and clinical practice. In addition it can help to promote self directed learning and teamwork and produce faster and better doctors.

Tests of Glycemia in Diabetes

Abstract: Monitoring of glycemic status, as performed by patients and health care providers, is considered a cornerstone of diabetes care. Results of monitoring are used to assess the efficacy of therapy and to make adjustments in diet, exercise, and medications in order to achieve the best possible blood glucose control. The purpose of this review is to summarize current knowledge about the tests used most widely in monitoring the glycemic status of people with diabetes. The review addresses both patient- and physician/laboratory-based testing, and it includes tests of urine glucose and ketones and tests of blood glucose and glycated proteins (hemoglobin and serum proteins). The major emphasis is on the advantages and limitations of each test for routine clinical practice. Use of these tests for diabetes screening and diagnosis will not be addressed in this review. Since this review was first published in 1995, there have been many advances in the field, most notably standardization of glycated hemoglobin testing and new approaches to self-monitoring of blood glucose (SMBG), including minimally invasive continuous glucose monitoring over hours to days at a time. These and other advances are presented in detail in a recent report that was prepared by the National Academy of Clinical Biochemistry (NACB) and published as an American Diabetes Association (ADA) position statement (1). This review will attempt to complement, rather than duplicate, the material in the NACB report. If there was an ideal method of monitoring glycemic status, it might be a small noninvasive device, perhaps similar to a wristwatch that people with diabetes could wear to continuously monitor their blood glucose level. The device would warn of impending hypoglycemia. It also would store blood glucose data and perform a variety of calculations such as hourly, daily, weekly, or monthly blood glucose averages. Unfortunately, such a monitoring device is …

Inadequate functional health literacy among patients at two public hospitals.

Abstract: Objective. —To determine the ability of patients to complete successfully basic reading and numeracy tasks required to function adequately in the health care setting. Design. —Cross-sectional survey. Setting. —Two urban, public hospitals. Patients. —A total of 2659 predominantly indigent and minority patients, 1892 English-speaking and 767 Spanish-speaking, presenting for acute care. Main Outcome Measure. —Functional health literacy as measured by the Test of Functional Health Literacy in Adults (TOFHLA), an instrument that measures ability to read and understand medical instructions and health care information presented in prose passages and passages containing numerical information (eg, prescription bottle labels and appointment slips). Results. —A high proportion of patients were unable to read and understand written basic medical instructions. Of 2659 patients, 1106 (41.6%) were unable to comprehend directions for taking medication on an empty stomach, 691 (26%) were unable to understand information regarding when a next appointment is scheduled, and 1582 (59.5%) could not understand a standard informed consent document. A total of 665 (35.1%) of 1892 English-speaking patients and 473 (61.7%) of 767 Spanish-speaking patients had inadequate or marginal functional health literacy. The prevalence of inadequate or marginal functional health literacy among the elderly (age ≥60 years) was 81.3% (187/230) for English-speaking patients and 82.6% (57/69) for Spanish-speaking patients, and was significantly higher ( P Conclusions. —Many patients at our institutions cannot perform the basic reading tasks required to function in the health care environment. Inadequate health literacy may be an important barrier to patients' understanding of their diagnoses and treatments, and to receiving high-quality care. ( JAMA . 1995;274:1677-1682)

Drug-Related Morbidity and Mortality: A Cost-of-Illness Model

Abstract: Background: Preventable drug-related morbidity and mortality represent a serious medical problem that urgently requires expert attention. The costs to society of the misuse of prescription medications, in terms of morbidity, mortality, and treatment, can be immense. To date, research has primarily documented increased rates of hospitalization secondary to medication noncompliance and/or adverse drug effects. Objectives: To develop a conceptual model of drug-related morbidity and mortality, and to estimate the associated costs in the ambulatory setting in the United States. Methods: A probability pathway model was developed to estimate the cost of drug-related morbidity and mortality in the United States. Pharmacist practitioners were surveyed to determine conditional probabilities of therapeutic outcomes owing to drug therapy. Health care utilization and associated costs owing to negative therapeutic outcomes were estimated. Results: Drug-related morbidity and mortality was estimated to cost $76.6 billion in the ambulatory setting in the United States. The largest component of this total cost was associated with drug-related hospitalizations. When assumptions of the model were varied, the estimated cost ranged from a conservative estimate of $30.1 to $136.8 billion in a worst-case scenario. Conclusions: The cost of drug-related morbidity and mortality in the ambulatory setting in the United States is considerable and should be considered in health policy decisions with regard to pharmaceutical benefits. Policies and services should be developed to reduce and prevent drug-related morbidity and mortality. (Arch Intern Med. 1995;155:1949-1956)

Preventable hospitalizations and access to health care

Abstract: Objective. —To examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style. Design. —Analysis of California hospital discharge data. We calculated the hospitalization rates for these five chronic conditions for the 250 ZIP code clusters that define urban California. We performed a random-digit telephone survey among adults residing in a random sample of 41 of these urban ZIP code clusters stratified by admission rates and a mailed survey of generalist and emergency physicians who practiced in the same 41 areas. Setting. —Community based. Participants. —A total of 6674 English- and Spanish-speaking adults aged 18 through 64 years residing in the 41 areas were asked about their access to care, their chronic medical conditions, and their propensity to seek health care. Physician admitting style was measured with written clinical vignettes among 723 generalist and emergency physicians practicing in the same communities. Main Outcome Measures. —We compared respondents' reports of access to medical care in an area with the area's cumulative admission rate for these five chronic conditions. We then tested whether access to medical care remained independently associated with preventable hospitalization rates after controlling for the prevalence of the conditions, health care seeking, and physician practice style. Results. —Access to care was inversely associated with the hospitalization rates for the five chronic medical conditions ( R 2 =0.50; P P P Conclusion. —Communities where people perceive poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely than changing patients' propensity to seek health care or eliminating variation in physician practice style to reduce hospitalization rates for chronic conditions. ( JAMA . 1995;274:305-311)

Users' Guides to the Medical Literature: IX. A Method for Grading Health Care Recommendations

Abstract: THE ULTIMATE PURPOSE of applied health research is to improve health care. Summarizing the literature to adduce recommendations for clinical practice is an important part of the process. Recently, the health sciences community has reduced the bias and imprecision of traditional literature summaries and their associated recommendations through the development of rigorous criteria for both literature overviews 1-3 and practice guidelines. 4,5 Even when recommendations come from such rigorous approaches, however, it is important to differentiate between those based on weak vs strong evidence. Recommendations based on inadequate evidence often require reversal when sufficient data become available, 6 while timely implementation of recommendations based on strong evidence can save lives. 6 In this article, we suggest an approach to classifying strength of recommendations. We direct our discussion primarily at clinicians who make treatment recommendations that they hope their colleagues will follow. However, we believe that any clinician who attends to

Trends in Antimicrobial Drug Prescribing Among Office-Based Physicians in the United States

Abstract: Objective. —To assess changes in oral antimicrobial drug prescribing by office-based physicians from 1980 through 1992, with emphasis on the treatment of otitis media and sinusitis and on the possible impact of demographic variables on such use. Design. —The National Ambulatory Medical Care Survey is a sample survey of office-based physicians in the United States conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention. Setting. —Physicians' offices. Patients or Other Participants. —Physicians sampled for the 1980,1985,1989, and 1992 National Ambulatory Medical Care Surveys, which included groups of 2959,5032,2540, and 3000 physicians, respectively. Sample physicians responding in 1980, 1985, 1989, and 1992 reported data for 46081, 71 594, 38384, and 34 606 sample office visits, respectively, including information on antimicrobial drug prescribing. Main Outcome Measure. —Trends in the antimicrobial drug prescription rates. Results. —From 1980 through 1992, increasing prescribing measured by the annual drug prescription rate per 1000 population, was found for the more expensive, broad-spectrum antimicrobial drugs, such as the cephalosporins; decreasing rates were observed for less expensive antimicrobial drugs with a narrower spectrum, such as the penicillins. No trend was found for trimethoprim-sulfamethoxazole, the erythromycins, or the tetracyclines. During the decade, an increasing trend in the visit rate to office-based physicians for otitis media was observed, while the visit rate for sinusitis among adults was found to be higher in 1992 than in each of the other study years. Conclusions. —The increased use of broader-spectrum and more expensive antimicrobial drugs have implications for all patients because of the impact on health care costs and the potential for the emergence of antimicrobial resistance. The data suggest that the incidence of otitis media and sinusitis is increasing. ( JAMA . 1995;273:214-219)

A social tariff for EuroQol: results from a UK general population survey

Abstract: An important consideration when establishing priorities in health care is the likely effects that alternative allocations of resources will have on health-related quality of life (HRQoL). This paper reports on the analysis of data from a study which elicited health state valuations (using the time trade-off (TTO) method) from a representative sample of the UK health population. Health states were defined in terms of the EuroQol Descriptive System which generates 243 theoretically possible states. Because it was impossible to generate direct valuations for all of these states, it was necessary to find a procedure that allowed interpolation of valuations for all EuroQol states from direct valuations on a subset of these. This paper describes (in as non-technical manner as possible) the modelling technique used to generate a set of EuroQol valuations from directly observed valuations on 45 states. The specification of the models tested was derived from the ordinal nature of the EuroQol descriptive system, in which the value assigned to a particular state depends on the level of each dimension. Data were analysed at the individual level using a generalised least squares regression technique. A model that fitted the data well and that was readily interpretable was one in which valuations were explained in terms of three different elements: 1) the level of severity associated with each dimension independently of the levels of the other dimensions; 2) an intercept associated with any move away from full health; and 3) a term which identified whether any dimension was at its most severe level. The coefficients on these variables can be used to build up a fill ‘tariff’ of EuroQol values representing the views of a representative sample of the UK adult population. This social tariff has a number of potential uses, including the measurement of the likely impact on health status of different health care programmes or policies.

Guidelines for the Evaluation and Management of Heart Failure Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure)

Abstract: It is becoming more apparent each day that despite a strong national commitment to excellence in health care, the resources and personnel are finite. It is, therefore, appropriate that the medical profession examine the impact of developing technology and new therapeutic modalities on the practice of cardiology. Such analysis, carefully conducted, could potentially have an impact on the cost of medical care without diminishing the effectiveness of that care. To this end, the American College of Cardiology and the American Heart Association in 1980 established a Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (now the ACC/AHA Task Force on Practice Guidelines) with the following charge: The task force of the American College of Cardiology and the American Heart Association shall develop guidelines relative to the role of new therapeutic approaches and of specific noninvasive and invasive procedures in the diagnosis and management of cardiovascular disease. The task force shall address, when appropriate, the contribution, uniqueness, sensitivity, specificity, indications, contraindications and cost-effectiveness of such diagnostic procedures and therapeutic modalities. The task force shall emphasize the role and values of the developed guidelines as an educational resource. The task force shall include a chair and eight members, four representatives from the American Heart Association and four representatives from the American College of Cardiology. The task force may select ad hoc members as needed upon the approval of the presidents of both organizations. Recommendations of the Task Force are forwarded to the President of each organization. The members of the task force are Melvin D. Cheitlin, MD, Kim A. Eagle, MD, Timothy J. Gardner, MD, Arthur Garson, Jr, MD, MPH, Raymond J. Gibbons, MD, Richard P. Lewis, MD, Robert A. O’Rourke, MD, Thomas J. Ryan, MD, and James L. Ritchie, MD, Chair. The Committee to Develop Guidelines on the Evaluation …

Survival of cancer patients in Europe: The Eurocare Study

Abstract: Part 1: Introduction and Methodology F Berrino, J Esteve and MP Coleman: Chapter 1 Basic issues in estimating and comparing the survival of cancer patients M Sant and G Gatta: Chapter 2 The EUROCARE database A Verdecchia, R Capocaccia and T Hakulinen: Chapter 3 Methods of data analysis A Micheli and R Capocaccia: Chapter 4 General mortality and its effects on survival estimates Part 2: Contributing Cancer Registries and Results HH Storm: Chapter 5 Health care system, cancer registration and follow-up of cancer patients in Denmark T Aareleid: Chapter 6 Health care system, cancer registration and follow-up of cancer patients in Estonia T Hakulinen: Chapter 7 J Faivre, PM Carli, G Chaplain, D Pottier, N Raverdy, J Robillard and S Schraub: Chapter 8 Health care system, cancer registration and follow-up of cancer patients in France H Ziegler, P Kaatsch and J Michaelis: Chapter 9 Health care system, cancer registration and follow-up of cancer patients in Germany M Sant, G Gatta, A Barchielli, EMS Conti, L Gufa, C Magnani and M Ponz de Leon: Chapter 10 Health care system, cancer registration and follow-up of cancer patients in Italy JWW Coebergh, MA Crommelin, E Masseling and LH van der Heijden: Chapter 11 Health care system, cancer registration and follow-up of cancer patients in The Netherlands J Pawlega: Chapter 12 Health care system, cancer registration and follow-up cancer patients in Poland P Viladiu: Chapter 13 Health care system, cancer registration and follow-up of cancer patients in Spain L Raymond and J Torhorst: Chapter 14 Health care system, cancer registration and follow-up of cancer patients in Switzerland S Wilson, J Bell, R Black, MP Coleman, C Cummins, G Lawrence, M Page, L Rider, J Smith and J Youngson: Chapter 15 Health care system, cancer registration and follow-up of cancer patients in the United Kingdom

Health-care costs associated with depressive and anxiety disorders in primary-care

Abstract: Objective: The authors examined the overall health care costs associated with depression and anxiety among primary care patients. Method: I 1 0 consecutive primary care patients in a health maintenance organization, 1,962 were screened with the 12-item General Health Questionnaire. A stratified random sample of6l 5 patients were selected for further diagnostic assessment; 3 73 ofthese patients completed the Composite International Diagnostic Interview at baseline and 328 were reassessed 12 months later. Computerized cost records were used to calculate total health care costs for the 6-month period surrounding the baseline assessment and a similar period surrounding the follow-up assessment. Cost accounting data were available for 327 patients at baseline and for 206 patients at both assessments. Results: Primary care patients with DSM-III-R anxiety or depressive disorders at baseline had markedly higher baseline costs ($2,390) than patients with subthreshold disorders ($1,098) and those with no anxiety or depressive disorder ($ I ,3 97). Large cost differences persisted after adjustment for medical morbidity. Cost differences reflected higher utilization of general medical services rather than higher mental health treatment costs. Although most patients with baseline anxiety or depressive disorders showed significant improvement, longitudinal analyses did not show any clear relationship between change in psychiatric diagnosis and change in health care cost. Conclusions: Among primary care patients, anxiety and depressive disorders are associated with markedly higher health care costs even after adjustment for medical comorbidity. In this small sample, improvement in depression over 1 year was not clearly associated with decreases incost. (AmJ Psychiatry 1995; 152:352-357)

Community health workers: integral members of the health care work force.

Abstract: As the US health care system strives to function efficiently, encourage preventive and primary care, improve quality, and overcome nonfinancial barriers to care, the potential exists for community health workers to further these goals. Community health workers can increase access to care and facilitate appropriate use of health resources by providing outreach and cultural linkages between communities and delivery systems; reduce costs by providing health education, screening, detection, and basic emergency care; and improve quality by contributing to patient-provider communication, continuity of care, and consumer protection. Information sharing, program support, program evaluation, and continuing education are needed to expand the use of community health workers and better integrate them into the health care delivery system.

Recognition, management, and outcomes of depression in primary care.

Abstract: OBJECTIVE To evaluate the recognition, management, and outcomes of depressed patients presenting in primary care. DESIGN Epidemiologic survey with 12-month follow-up. SETTING Primary care clinics of a staff-model health maintenance organization. PATIENTS AND MAIN OUTCOME MEASURES Consecutive primary care attenders aged 18 to 65 years (n = 1952) were screened using the 12-item General Health Questionnaire (GHQ-12), and a stratified random sample (n = 373) completed a psychiatric assessment, including the Composite International Diagnostic Interview (CIDI), the 28-item GHQ, and a brief self-rated disability questionnaire (BDQ). Three-month follow-up assessment (n = 347) repeated the GHQ-28 and BDQ, and 12-month follow-up (n = 308) repeated the CIDI, GHQ-28, and BDQ. Use of psychotropic drugs and mental health services was assessed using computerized pharmacy and visit registration records. RESULTS Structured interviews found 64 cases of current major depression (weighted prevalence, 6.6%) and 58 cases of current subthreshold depression (weighted prevalence, 8.8%). Of those with major depression, 64% (n = 41) were recognized as psychologically distressed by the primary care physician, 56% (n = 36) filled at least one antidepressant prescription during the next 3 months, and 39% (n = 25) made at least one specialty mental health visit. Compared with recognized cases, those with unrecognized major depression were less symptomatic at baseline (GHQ-28 score, 15.31 vs 11.07; P = .006) but showed a similar rate of improvement over 12 months (F test for difference in slopes, P = .93). CONCLUSIONS While many depressed primary care patients may go unrecognized and untreated, this group appears to have milder and more self-limited depression. A narrow focus on increased recognition may not improve overall outcomes. Treatment resources might be best directed toward more intensive follow-up and relapse prevention among those now treated.

The Outcomes and Costs of Care for Acute Low Back Pain among Patients Seen by Primary Care Practitioners, Chiropractors, and Orthopedic Surgeons

Abstract: Background Patients with back pain receive quite different care from different types of health care practitioners. We performed a prospective observational study to determine whether the outcomes of and charges for care differ among primary care practitioners, chiropractors, and orthopedic surgeons. Methods Two hundred eight practitioners in North Carolina were randomly selected from six strata: urban primary care physicians (n = 39), rural primary care physicians (n = 48), urban chiropractors (n = 32), rural chiropractors (n = 32), orthopedic surgeons (n = 29), and primary care providers at a group-model health maintenance organization (HMO) (n = 28). The practitioners enrolled consecutive patients with acute low back pain. The patients were contacted by telephone periodically for up to 24 weeks to assess functional status, work status, use of health care services, and satisfaction with the care received. Results The status at six months was ascertained for 1555 of the 1633 patients enrolled in the study...

Intelligent remote visual monitoring system for home health care service

Abstract: A computer-based remote visual monitoring system is provided for in-home patient health care from a remote location via ordinary telephone lines. The system includes a supervisory control center having access to patient and health care professional databases for assigning patients to appropriate health care professionals and for performing task planning. A number of master monitoring computers are linked to the control center and are accessible by a corresponding number of health care professionals. A slave monitoring computer is located within the homes of a plurality of patients and may be linked via telephone modems to any of the master monitoring computers. Audio/visual equipment at both locations permits real-time two-way communications during an "in-home" visit to a patient by a health care professional from a remote location. The health care professional has control over the audio/visual equipment in the patient's home as well as the communication of multimedia data via the master monitoring computer, and may automatically generate and maintain the patient's multimedia medical records.

Critical Pathways as a Strategy for Improving Care: Problems and Potential

Abstract: In an era of increasing competition in medical care, critical pathway guidelines have emerged as one of the most popular new initiatives intended to reduce costs while maintaining or even improving the quality of care. Developed primarily for high-volume hospital diagnoses, critical pathways display goals for patients and provide the corresponding ideal sequence and timing of staff actions for achieving those goals with optimal efficiency. Despite the rapid dissemination of critical pathway programs in hospitals throughout the United States, many uncertainties remain about their development, implementation, and evaluation. In addition, serious concerns have been raised about their effect on patient outcomes and satisfaction with care, physician autonomy, malpractice risks, and the teaching and research missions of many hospitals. Underlying these concerns is the absence of data from controlled trials to evaluate the effects of critical pathways. Physicians should understand the potential benefits and problems associated with critical pathways because physicians are increasingly being asked to provide leadership for pathway programs. Physicians and other health service investigators should also develop methods to study pathways in evolving health care settings. Although the promise of reduced costs and improved quality is enticing, the gaps in our knowledge about critical pathways are extensive; therefore, like any new health care technology, pathway programs should be fully evaluated in order to understand the conditions under which that promise may be fulfilled.

Health care costs of primary care patients with recognized depression.

Abstract: Background: While an extensive literature documents the influence of depression on general medical services utilization, estimates of the economic burden of depression have focused on the direct costs of depression treatment. Higher use of general medical services may contribute significantly to the true cost of depressive illness. Methods: Computerized record systems of a large staffmodel health maintenance organization (HMO) were used to identify consecutive primary care patients with visit diagnoses of depression (n=6257) and a comparison sample of primary care patients with no depression diagnosis (n=6257). The HMO accounting records were used to compare components of health care costs. Results: Patients diagnosed as depressed had higher annual health care costs ($4246 vs $2371, P Conclusions: Diagnosis of depression is associated with a generalized increase in use of health services that is only partially explained by comorbid medical conditions. In the primary care sector, this greater medical utilization exceeds direct treatment costs for depression. The persistence of utilization differences suggests that recognition and initiation of treatment alone are not adequate to reduce utilization differences.

Depression in women: implications for health care research

Abstract: Epidemiologic data from around the world demonstrate that major depression is approximately twice as common in women than men and that its first onset peaks during the childbearing years. Progress has been made in understanding the epidemiology of depression and in developing effective treatments. Much remains to be learned about the basic pathogenesis of depression and the specific treatment needs of depressed women and their offspring, especially during the reproductive years.