Showing papers on "Referral published in 1990"

Increased Mortality of Women in Coronary Artery Bypass Surgery: Evidence for Referral Bias

Abstract: Study Objective:To determine whether differences in referral reasons explain the higher operative mortality of women in coronary artery bypass surgery. Design:Case series. Setting:A tertia...

Neglected factors in chronic pain treatment outcome studies--referral patterns, failure to enter treatment, and attrition.

Abstract: An increasing number of chronic pain treatment outcome studies have appeared in the literature. In general, these studies support the efficacy of multidisciplinary pain programs, as well as specific treatment modalities such as biofeedback and relaxation. Reviews of this literature have tended to be cautiously optimistic. Some concerns, however, have been raised about the methodological adequacy of these studies, particularly in terms of the lack of control groups, the brief duration of follow-up periods, and the vague criteria used for establishing the success of the therapeutic interventions. Other factors that mitigate conclusions regarding the generalizability of the favorable results reported need to be considered. In this paper 3 rarely discussed topics that are implicit within most treatment outcome studies and that need to be given greater attention are examined. These topics include: 1. (1) referral patterns to pain clinics (who are referred to pain clinics, when, and how representative is the referred sample?); 2. (2) failure to enter treatment (e.g., exclusion criteria, lack of available financial support to cover the cost of treatment, patient's refusal to accept recommendations), and consequently, the representativeness of the treated sample; 3. (3) patient's attrition. In this paper we discuss each of these factors as they underscore important qualifications that have to be made in evaluating treatment outcome studies.

The pediatrician as gatekeeper to mental health care for children: do parents' concerns open the gate?

Abstract: Data from a study of children seen for pediatric care in a Health Maintenance Organization are used to examine factors which influence the likelihood that a pediatrician will identify a psychiatric problem and refer an identified child to a mental health specialist for further evaluation and treatment. Parental level of distress, family psychiatric history, and discussion of parental concerns with the pediatrician were found to be important. Characteristics of the service delivery system which may impede appropriate identification and referral are discussed. Implications for participation of child and adolescent psychiatrists in the training of pediatricians are presented.

A study of communication between general practitioners and specialists.

Abstract: A random sample of referral letters from general practitioners to outpatient departments of general medicine, dermatology, neurology, and gastroenterology at an Amsterdam teaching hospital were analysed together with the specialists' replies for 144 referrals. The pairs of letters were judged by a panel of four general practitioners and four specialists. Letters were assessed according to quality and content, clarity, request for return to general practitioner care, time intervals between referral and consultation and between consultation and the specialist's reply. The judges were also asked to assess whether in their opinion the letters were of value in teaching or were discourteous. Though in general intraobserver agreement on what constitutes a good letter was low, deficiencies were revealed in the quality of letters and there were delays in transmission and missed educational opportunities.

Home treatment for acute psychiatric illness.

Abstract: OBJECTIVE--To determine the factors influencing the successful outcome of community treatment for severe acute psychiatric illnesses that are traditionally treated in hospital. DESIGN--All patients from a single electoral ward who were either admitted to hospital or treated at home over a two year period (1 October 1987 to 30 September 1989) were included in the study and their case notes audited. The second year of the study is reported. SETTING--Electoral ward of Sparkbrook, Birmingham. SUBJECTS--99 Patients aged 16-65 with severe acute psychiatric illness. RESULTS--65 Patients were managed by home treatment alone; 34 required admission to hospital. The location of treatment was significantly (all p less than 0.05) influenced by social characteristics of the patients (marital state, age (in men), ethnicity, and living alone) and by characteristics of the referral (occurring out of hours; assessment taking place at hospital or police station). DSM-III-R diagnosis was more weakly associated with outcome. Violence during the episode was significantly related to admission, although deliberate self harm was not. CONCLUSIONS--Home treatment is feasible for most patients with acute psychiatric illness. A 24 hour on call assessment service increases the likelihood of success because admission is determined more strongly by social characteristics of the patient and the referral than by illness factors. Admission will still be required for some patients. A locally based mental health resource centre, a 24 hour on call service, an open referral system, and an active follow up policy increase the effectiveness of a home treatment service.

Can Prediction of Violence Among Psychiatric Inpatients Be Improved

Abstract: In an effort to improve the prediction of violence among psychiatric inpatients, the authors retrospectively studied 25 patients who were violent and 34 who were not violent after admission to a psychiatric emergency ward in Norway. The only demographic variable that discriminated between the two groups was violence in the family of origin; the violent group had experienced significantly more. The best single predictor of violence was a history of previous violence by the patient, which correctly classified 80 percent of the patients. The combined information about patients' level of aggression rated at referral and level of anxiety rated at admission correctly classified 78 percent. In a subgrouping of violent patients who inflicted injuries and did not inflict injuries, a higher percentage of the injury-inflicting patients were found to have a diagnosis of schizophrenia. These patients also had a higher level of aggression at referral.

The use of alternative therapies by Auckland general practitioners.

Abstract: A survey of Auckland general practitioners was undertaken to explore their use of, and attitudes to, alternative medicines. Three hundred and seventy randomly selected doctors, from a total of about 700 doctors practising in Auckland, were posted questionnaires. Of 249 respondents, 75 (30%) practised one or more forms of alternative medicine. Acupuncture was the therapy most commonly used. Musculoskeletal disorders and chronic pain syndromes were the most frequently treated conditions. A total of 171 (68.7%) respondents referred patients to one or more forms of alternative treatment, and only 56 (32.7%) of these felt it necessary that the person referred to be medically qualified. Younger doctors were more inclined to refer and the most commonly cited reason for referral was failure of conventional medicine.

Recruitment and retention of rural physicians: Issues for the 1990s

Abstract: This paper briefly describes a number of structural and economic changes in the profession of medicine and in the rural medical care delivery system that have occurred since about 1970. Changes in the national physician supply; in the training, work, and practice characteristics of physicians; in the demographic characteristics of physicians; in the medical resources available in rural communities; and in federal and state support for the provision of medical services are noted. Four conceptual models that underlie physician recruitment and retention programs for small towns and rural communities are described. These include affinity models, which attempt to recruit rural persons into training or foster interest in rural practice among trainees; economic incentive models, which address reimbursement or payment mechanisms to increase economic rewards for rural practice; practice characteristics models, which address technical, collegial, referral, and other structural barriers to rural practice; and indenture models, which recruit temporary providers in exchange for scholarship support, loan forgiveness, or licensure. Examples of applications of each model are provided and the effects of changes in the medical care system on the effectiveness of each model are assessed. Finally, it is argued that elements of an optimal model for the recruitment of physicians to rural practice include the promotion of medical careers among rural high school students, the provision of financial and cultural support for their training, the development of technical and collegial support systems, and the limited use of indenture mechanisms to meet the needs of the most impoverished or isolated rural settings.

Prevention of suicide

Abstract: We reviewed the epidemiologic features of suicide in Canada and evaluated suicide prevention programs. Three groups were found to be at increased risk for suicide: men aged 70 years or more, women aged 65 to 69 and men aged 20 to 24. The other groups, in decreasing order of risk, were the mentally ill, people who have attempted suicide, those with a life-threatening illness, native people, people with a family history of suicide and prisoners. Studies that evaluated suicide prevention programs showed that none significantly reduced the incidence of suicide; however, the studies were found to be methodologically inadequate or used noncomparable systems of data collection. On the basis of our findings we recommend that primary care physicians routinely evaluate suicide risk among patients in high-risk groups and that intervention include counselling, follow-up and, if necessary, referral to a psychiatrist. Close follow-up is recommended for newly discharged psychiatric patients and those who recently attempted suicide.

Prevention of eating disorders among adolescents.

Abstract: Since eating disorders frequently begin during adolescence, high school students represent a high risk population for the development of these disorders. For this reason, a pilot project for the prevention of eating disorders was instituted at the high school level. The primary goal of this pilot project was to educate students, faculty, and staff at the school about the incidence, symptoms, and consequences of eating disorders. Consultation and referral services were also provided. An evaluation component of the project assessed the informational impact of the prevention program on the students. On a questionnaire designed for the project, a significantly greater number of questions about eating disorders were answered correctly by students who were recipients of the prevention program than by those who were not. The results of this project demonstrate the feasibility of using the high school setting to promote increased awareness of eating disorders and their consequences among high school stud...

A comparison of hospice and home care patients: patterns of referral, patient characteristics and predictors of place of death

Abstract: A retrospective review was performed of all patients cared for by St Joseph's Hospice, Hackney, London, in either the hospice or the home care setting, during the first six months of 1988. Patients referred to the two services were compared and home care patients further analysed to establish predictors of those who could be successfully managed at home. The results showed that those patients referred to the home care service were younger and more likely to be married. Hospitals were more likely to refer to the hospice, while community services referred more often to home care. Home care patients were likely to have a longer prognosis but were more likely to be recorded as experiencing anxiety/depression at presentation. Patients referred for home care were significantly more likely to die at home than in hospital. Those who did die at home were more likely to be married, less likely to be described as their own main carer and less likely to have been recorded as suffering moderate/severe pain at presenta...

A Comparative Review of Developmental Screening Tests

Abstract: Public Law 99-457 amends the Education of the Handicapped Act to include services for children from birth through 3 years. Inasmuch as detection and referral of children with developmental delays continues to reside largely with pediatricians and other health care professionals, developmental screening, using standardized tests, is increasingly important. To help physicians select from the array of instruments, 19 different screening tests were administered by a pediatrician and rated by a panel of pediatricians and a special educator. While the panel found few tests that fit within the time constraints of pediatric practice, several tests approached standards for educational and psychologic tests. These included the Battelle Developmental Inventory Screening Test, Infant Monitoring System, Developmental Indicators for Assessment of Learning-Revised, Screening Children for Related Early Educational Needs, and the Developmental Profile II.

Orthopaedic aspects of fragile-X syndrome

Abstract: Fragile-X syndrome is one of the most common inherited forms of mental retardation. An associated connective-tissue disorder involving elastin accounts for the most frequent musculoskeletal manifestations, which include severe flexible flat feet, excessive laxity of the joints, and scoliosis. At our institution, seventy-five (50 per cent) of the 150 male patients who had fragile-X syndrome had flat feet, eighty-five (57 per cent) had excessive laxity of the joints, and ten had scoliosis. Twenty-nine of the patients who had flat feet had been evaluated or treated, or both, by an orthopaedic surgeon before the diagnosis of fragile-X syndrome had been made. Only one of these patients had been referred for developmental and genetic evaluation, which suggests that the orthopaedic community is not familiar with this syndrome. The orthopaedist should consider the diagnosis of fragile-X syndrome in the evaluation of a mentally retarded boy or man who has a family history of mental retardation. The presence of flat feet and excessive laxity of the joints, associated with the characteristic facies, macro-orchidism, and behavior, justifies a referral for developmental and genetic evaluation. Early diagnosis is important for several reasons, including genetic counseling for the family, more efficacious medical treatment, and specialized education.

Relation between general practices' outpatient referral rates and rates of elective admission to hospital.

Abstract: OBJECTIVE--To examine the variation in rates of admission to hospital among general practices, to determine the relation between referral rates and admission rates, and to assess the extent to which variations in outpatient referral rates might account for the different patterns of admission. DESIGN--A comparison of outpatient referral rates standardised for age and sex and rates of elective admission to hospital for six specialties individually and for all specialties combined. SETTING--19 General practices in three districts in Oxford Regional Health Authority with a combined practice population of 188 610. MAIN OUTCOME MEASURES--Estimated proportion of outpatient referrals resulting in admission to hospital, extent of variation in referral rates and admission rates among practices, and association between admissions and outpatient referrals. RESULTS--Patients referred to surgical specialties were more likely than those referred to medical specialties to be admitted after an outpatient referral. Overall, the estimated proportion of patients admitted after an outpatient referral was 42%. There were significant differences among the practices in referral rates and admission rates for most of the major specialties. The extent of systematic variance in admission rates (0.048) was similar to that in referral rates (0.037). Referral and admission rates were significantly associated for general surgery; ear, nose, and throat surgery; trauma and orthopaedics; and all specialties combined. For most specialties the practices with higher referral rates also had higher admission rates, casting doubt on the view that these practices were referring more patients unnecessarily. CONCLUSION--Rates of elective admission to hospital vary systematically among general practices. Variations in outpatient referral rates are an important determinant of variations in admission rates.

Understanding hospital referral rates: a user's guide.

Abstract: Detailed referral information from one practice was used to investigate the effect of calculating referral rates in several different ways. Referral rates for individual general practitioners should be related to the number of consultations carried out and not to the number of registered patients; for whole practices list size may be used as the denominator. Most doctors will not need to control for age and sex of patients when comparing referral rates but may need to control for case mix when comparing referral rates to individual specialties. In addition, a method is described for distinguishing systematic variation between the referral rates of individual doctors from the random variation that may arise from data based on fairly small numbers of referrals. The method indicates whether systematic variation is greater than would be expected by chance, and it can be extended to indicate whether variability in referral rates is greater in one specialty than another. Because of random variation with time a year's data may not be sufficient to allow reliable interpretation of referral rates to individual specialties, except for the largest. At present there is no known relation between high or low referral rates and quality of care. Nevertheless, if doctors are to interpret their own rates of referral they need those rates to be reliable and valid. Use of the 10 guidelines described in this paper will help to prevent unwarranted conclusions being drawn from information on general practitioners' rates of referral to hospital.

Comparing the quality of referrals of general practitioners with high and average referral rates: an independent panel review.

Abstract: The quality of referrals of four general practitioners, two with high and two with average rates of referral to the department of internal medicine, was judged by an independent expert panel. The panel, consisting of two general practitioners and one specialist, reviewed a set of information about the referrals blindly and in random sequence. The same distribution of quality of referrals was found among the referrals of the two high referring general practitioners (n = 192) as among those of the general practitioners with average rates (n = 88); that is, 57% and 55% respectively, of the cases had clear medical indications for referral, while the data did not permit a conclusion in 15% and 10%, respectively, of the cases. Controlling for sex, age and status of the referral (first or repeat referral) did not alter the results. We conclude that using referral rates to judge referral quality is misleading. However, a blind and randomly performed panel review of referrals is a time consuming but feasible method of quality assessment.

Referral letters and replies from orthopaedic departments: opportunities missed.

Abstract: OBJECTIVE--To study delays between sending referral letters and the outpatient appointment and to assess the content of referral and reply letters, their educational value, and the extent to which questions asked are answered by reply letters. DESIGN--Retrospective review of referrals to 16 consultant orthopaedic surgeons at five hospitals, comprising 288 referral letters with corresponding replies, by scoring contents of letters. SETTING--Orthopaedic teaching hospitals in Nottingham, Derby, and Mansfield. MAIN OUTCOME MEASURES--Weighted scores of contents of referral and reply letters, assessment of their educational value, and responses to questions in referral letters. RESULTS--Median outpatient delay was 23.4 weeks. There was no significant decrease in waiting time if the referral letter was marked "urgent" but a significantly greater delay (p less than 0.01) if referrals were directed to an unnamed consultant. The content score was generally unsatisfactory for both referrals and replies, and there was no correlation for the content scores of the referral letter and its reply (r = 0.13). Items of education were rare in the referral letters (8/288; 3%) and significantly more common in replies (75/288; 26%) (p much less than 0.001). Senior registrars were significantly more likely to attempt education than other writers (p less than 0.02). Education in replies was significantly related to increased length of the letter (p less than 0.05) and was more likely to occur if the referral was addressed to a named consultant (p less than 0.03). 48 (17%) Referral letters asked questions, of which 21 (44%) received a reply. No factor was found to influence the asking of or replying to questions. CONCLUSIONS--The potential for useful communication in the referral letter and in the reply from orthopaedic surgeons is being missed at a number of levels. The content is often poor, the level of mutual education is low, and the use of the referral letter to determine urgency is deficient. Most questions asked by general practitioners are not answered.

Borderline personality disorder in primary care.

Abstract: Management of borderline patients requires skills that are at the heart of successful continuity of care. These skills include alliance-building, educating patients about their symptoms, referral, encouraging communication and cooperation in the health care team, utilizing community resources to sustain one's own professional development, and foreseeing and preventing morbidity. As trying as it may be to have a borderline patient in a practice, and as slow as progress with the patient may be, successful management of such patients will add poise, confidence, and maturity to the exercise of these invaluable primary care skills. More clinical and empirical discussion of borderline personality disorder is needed in the family practice literature. Probably no other professional is more likely to see such patients. The informed, motivated family physician, with the help of a supportive multidisciplinary team, can make invaluable contributions to reducing morbidity in borderline patients and can help avoid misunderstanding, frustration, and exhaustion in the health care team of the patient with this challenging disorder.

General practitioner referral rates to district psychiatry and psychology services.

Abstract: The number of referrals made to a district psychiatry service by each of the local general practitioners over a five year period was counted and a large variation in general practitioner referral rate was found. Ten referral letters from each of the general practitioners were independently assessed for the amount of detail included and a mean score for each general practitioner obtained. A significant negative correlation was found between referral rate and amount of detail in referral letters, that is low referrers wrote very detailed letters. The procedure was repeated over an 18 month period including referrals to the district psychology service. Referral rate to the psychologists was positively correlated with detailed referral letters, that is those who referred many patients to the psychologists wrote detailed letters. This study has indicated a wide variation in the use of the psychiatry and psychology services by general practitioners which cannot be explained solely on the basis of a general referral tendency. It is likely that constructive liaison between psychiatrists and general practitioners, especially those who refer a large number of patients, could enhance the care of patients with psychiatric disorder in general practice.

Mental health referral: a weak link in comprehensive care of children with chronic physical illness.

Abstract: Although children with chronic medical conditions are at increased risk for mental health problems, they and their families receive few mental health services. For a number of reasons, it is unusually difficult to refer these youngsters to traditional mental health resources and this may contribute to the paucity of services that they receive. Significant barriers to referral are contributed by each participant in the process: families, medical staff, and mental health providers. Alternative approaches to the delivery of services to this high-risk population are suggested.

The diabetes physician and an assessment and treatment programme for male erectile impotence.

Abstract: The feasibility has been investigated of a physician in a district general hospital implementing an assessment and treatment service for male erectile impotence Over an 8-month period a questionnaire was given to 200 men attending a diabetes review clinic There were 50 replies declaring a problem of impotence, 34 of whom expressed interest in discussing treatment These men and 17 others who spontaneously mentioned an impotence problem were further assessed with a view to treatment After a full assessment and discussion the following treatments were agreed and successfully implemented: no treatment 30 (59%), self-injection of papaverine 12 (24%), urology referral 4 (8%), psychosexual clinic referral 2 (4%), vacuum devices 2 (4%), adjustment of drug therapy 1 (2%) Only 18% of questionnaire respondents ultimately opted for active treatment compared with 88% of the spontaneous complainants A successful impotence assessment and treatment service, including self-injection of vasoactive drugs, can be provided by a physician as part of the diabetes care service Active treatment is gratefully accepted The numbers involved are manageable if resources are concentrated on those spontaneously mentioning the problem Our experience suggested self-injection of vasoactive drugs to be the most successful treatment option

Analysis of referral behaviour: responses to simulated case histories may not reflect real clinical behaviour.

Abstract: In an attempt to develop a measure of the referral behaviour of general practitioners, 21 simulated case histories were constructed which presented between three and six stages at which a decision was required whether or not refer a 'patient' to hospital. Twenty general practitioners completed the case histories and their responses were compared with their referral rates to outpatient departments. No significant correlations were found between the doctors' responses to the vignettes and their actual referral rates, and the repeatability of the vignettes was disappointing. The fact that the case histories appeared realistic to the doctors who completed them was not reflected in objective measures of their validity. Simulated case histories should not be used as a method of measuring doctors' behaviour without establishing their validity and reliability.

Identifying major concerns of persons with acquired immunodeficiency syndrome: a replication.

Abstract: A descriptive study was conducted at two major medical centers in Boston to identify and categorize major concerns of persons with acquired immunodeficiency syndrome. Thirty-four subjects were interviewed using a semistructured instrument, developed by Spross and her colleagues while at the National Institutes of Health. Obtained by referral from nurses caring for them in inpatient and outpatient settings, the majority of subjects were Caucasian, homosexual males from the Boston metropolitan area. The mean age of subjects was 33.6, with 71% less than 35 years old. Subjects reported an average of 3.2 hospitalizations since the AIDS diagnosis had been made; average time since diagnosis was 8 months. Information obtained from subjects included impact of diagnosis, major concerns and sources/types of support perceived to be helpful. Five themes were identified: uncertainty of the future; desire to maintain health; social unacceptability; fatigue; and weight loss.

Pediatric critical care transport survey: team composition and training, mobilization time, and mode of transportation.

Abstract: A survey was conducted to determine the current standard of care with regard to team composition and training, mobilization time, and vehicle use for pediatric critical care transport. An evaluation of 30 pediatric referral centers revealed that 60% provide a critical care transport team. Of those teams, the mean number of transports per year was 304. Response time ranged from 10 to 90 minutes. All teams included a physician all or most of the time; 100% of teams included a critical care nurse, and 50% always included a respiratory therapist. Ambulances alone are used in 28% of systems, with the remainder using combinations of ambulances, helicopters, and fixed wing aircraft. A proposal is presented for future standards in pediatric critical care transport with regard to the factors discussed.