Showing papers on "Referral published in 1993"

Brief interventions for alcohol problems: a review

Abstract: Relatively brief interventions have consistently been found to be effective in reducing alcohol consumption or achieving treatment referral of problem drinkers. To date, the literature includes at least a dozen randomized trials of brief referral or retention procedures, and 32 controlled studies of brief interventions targeting drinking behavior, enrolling over 6000 problem drinkers in both health care and treatment settings across 14 nations. These studies indicate that brief interventions are more effective than no counseling, and often as effective as more extensive treatment. The outcome literature is reviewed, and common motivational elements of effective brief interventions are described. There is encouraging evidence that the course of harmful alcohol use can be effectively altered by well-designed intervention strategies which are feasible within relatively brief-contact contexts such as primary health care settings and employee assistance programs. Implications for future research and practice are considered.

Teacher Efficacy and Student Problem as Factors in Special Education Referral

Abstract: We investigated the influence of teacher efficacy and student problem type on teachers' placement and referral decisions. Regular and special educators (N= 192) were randomly assigned a case study describing a student having a learning and/or behavior problem and asked to judge (a) whether the student was appropriately placed in regular education and (b) whether they would refer this student to special education. Analysis of an efficacy scale yielded two factors: personal efficacy and teaching efficacy. Results indicated that regular and special educators were most likely to agree with regular class placement when they were high in both dimensions of efficacy. Regular educators higher in personal efficacy were more likely to agree with regular education placement than those with lower personal efficacy. In addition, students with combined learning and behavior problems were found to be the most susceptible to referral. This study suggests that teachers' sense of efficacy underlies their placement decisions.

Primary care and public emergency department overcrowding.

Abstract: OBJECTIVES. Our objective was to evaluate whether referral to primary care settings would be clinically appropriate for and acceptable to patients waiting for emergency department care for nonemergency conditions. METHODS. We studied 700 patients waiting for emergency department care at a public hospital. Access to alternative sources of medical care, clinical appropriateness of emergency department use, and patients' willingness to use nonemergency services were measured and compared between patients with and without a regular source of care. RESULTS. Nearly half (45%) of the patients cited access barriers to primary care as their reason for using the emergency department. Only 13% of the patients waiting for care had conditions that were clinically appropriate for emergency department services. Patients with a regular source of care used the emergency department more appropriately than did patients without a regular source of care. Thirty-eight percent of the patients expressed a willingness to trade th...

Emergency medical services for children

Abstract: How can we meet the special needs of children for emergency medical services (EMS) when today's EMS systems are often unprepared for the challenge? This comprehensive overview of EMS for children (EMS-C) provides an answer by presenting a vision for tomorrow's EMS-C system and practical recommendations for attaining it. Drawing on many studies and examples, the volume explores why emergency care for children--from infants through adolescents--must differ from that for adults and describes what seriously ill or injured children generally experience in today's EMS systems. The book points the way to integrating EMS-C into current emergency programs and into broader aspects of health care for children. It gives recommendations for ensuring access to emergency care through the 9-1-1 system; training health professionals, from paramedics to physicians; educating the public; providing proper equipment, protocols, and referral systems; improving communications among EMS-C providers; enhancing data resources and expanding research efforts; and stimulating and supporting leadership in EMS-C at the federal and state levels. For those already deeply involved in EMS efforts, this volume is a convenient, up-to-date, and comprehensive source of information and ideas. More importantly, for anyone interested in improving the emergency services available to children--emergency care professionals from emergency medical technicians to nurses to physicians, hospital and EMS administrators, public officials, health educators, children's advocacy groups, concerned parents and other responsible adults--this timely volume provides a realistic plan for action to link EMS-C system components into a workable structure that will better serve all of the nation's children.

Determinants of Health Care Utilization — Visits and Referrals

Abstract: This study explores determinants of I) general practitioner (GP) visits and II) referrals (outpatient and hospitalization). The analyses were performed with regression models on a set of data from a comprehensive population study of 3533 men and 3578 women aged 40-42 in a county in Northern Norway. Among the various health status dimensions included, self-rated health was found to be the most important determinant, regardless of type of service. Factors, other than health status aspects affecting GP visits, were preoccupation with health and help seeking attitude. Volume of resources (GP per population), socio-demographic characteristics and social networks did not appear as important. Several inequitable effects were revealed on referrals: First, higher rate of referral of patients with higher educational achievement indicates a bias towards higher social status groups. Second, high GP/population ratio and residence in municipalities with referral care facilities were both found to be associated with higher probability of referral.

Outcome of spinal screening.

Abstract: Spinal screening using the Scoliometer was performed on one thousand high school students to determine the prevalence of spinal deformity and the appropriate degree of deformity to be used as a selection criterion. Eighty percent of students were found to have 3 degrees or more angle of trunk rotation (ATR). This new information predicts a referral rate of three percent if 7 degrees degrees ATR is used as referral criterion (12% referral if 5 degrees ATR is the criterion). A paradigm using the best available information on natural history and screening allows a comparison of the outcomes of screened versus non-screened school populations. Spinal screening appears to be effective in reducing the need for surgical treatment of scoliosis, but does not decrease the total cost of care for this problem. An appropriate referral criterion for spinal screening appears to be 7 degrees ATR at any level of the spine.

Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

Abstract: OBJECTIVES--To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines SETTING--Practices within Cambridge Health Authority and Addenbrooke's Hospital, Cambridge MAIN OUTCOME MEASURES--Data on practice referral rates from hospital computers, inappropriate referrals as judged by hospital consultants, and inappropriate referrals as judged against referral guidelines which had been developed locally between general practitioners and specialists Effect of referral guidelines on referral patterns as judged by general practitioners using the guidelines in clinical practice RESULTS--There was 25-fold variation in referral rates among general practices According to the specialists, 96% (95% confidence interval 64% to 129%) of referrals by general practitioners and 89% (26% to 152%) of referrals from other specialists were judged possibly or definitely inappropriate Against locally determined referral guidelines 159% of referrals by general practitioners were judged possibly inappropriate (118% to 200%) Elimination of all possibly inappropriate referrals could reduce variation in practice referral rates only from 25-fold to 21-fold An estimate of the effect of using referral guidelines for 60 common conditions in routine general practice suggested that application of guidelines would have been unlikely to reduce rates of referral in hospital (95% confidence interval -45% to 86% of consultations resulting in referral) CONCLUSION--The variation in referral rates among general practitioners in Cambridge could not be explained by inappropriate referrals Application of referral guidelines would be unlikely to reduce the number of patients referred to hospital

The referral of minority adolescents to community mental health centers.

Abstract: Few investigations have examined the referral of minority adolescents to community mental health clinics. This issue is especially critical in light of the increased attention given to mental health services for children and adolescents in recent years. The present study uses mental health clinic data from a large metropolitan area to explore whether African Americans and Mexican Americans entering mental health care do so through referrals that are more coercive than those made for Whites. The total sample consists of 2,460 adolescents aged 13-17; the results indicate that African-American adolescents are more likely than Whites to be referred by an external agency. When types of external agencies are considered, African Americans enter community mental health care more often than Whites through referrals from social agencies; Mexican Americans enter more often than Whites through school referrals. This paper suggests that African-American adolescents' overrepresentation in community mental health clinics may in part be due to their disproportionate contact with social and legal agencies and the propensity of these agencies to rely more often on the mental health system than on families or schools. Among all variables considered in the analyses for this paper, poverty status demonstrated the most consistent and powerful association with coercive referrals.

Who has a Problem, the Student or the Teacher? Differences in Teachers' Beliefs About Their Work with At‐risk and Integrated Exceptional Students

Abstract: In this study, teachers' assumptions and beliefs are explored about the needs of at‐risk and exceptional students, and about their roles and responsibilities in meeting such needs. Teachers appear to hold consistent and coherent belief systems which differ along an ordinal scale. At one end, ‘restorative’ beliefs assume that problems reside largely within the pupil, and therefore the teacher's duty is to refer the pupil for confirmatory assessment as soon as possible. At the other ‘preventive’ end, teachers assume that the environment, including instruction, plays a part in a student's problems. The teacher therefore attempts prereferral interventions, and requests assessment to identify instructional alternatives. This study provides evidence for the validity of the restorative‐preventive construct, reporting the results of both quantitative and qualitative analyses of interviews with 27 regular class elementary teachers. Teachers' ratings on the construct correlated significantly with their self‐ratings...

Endocrine profiles for outcome prediction from the intensive care unit

Abstract: ObjectiveTo evaluate the discriminating ability of various specific endocrine studies on patient outcome from the intensive care unit (ICU).DesignProspective cohort study of patients requiring intensive care.SettingAdult medical and coronary care units in a military referral hospital.PatientsA total

Quality of general practitioner referrals to outpatient departments: assessment by specialists and a general practitioner.

Abstract: Thirty eight specialists in one district health authority were asked to take part in a questionnaire survey to assess the appropriateness of referral and the quality of the referral letter for 20 consecutive new patients each. A total of 705 new patient referrals to 13 specialties were included in the study. Twelve of the 38 specialists were randomly selected and their 234 new patient referral letters were independently assessed by a general practitioner for the appropriateness of the referral decision. The study revealed errors and omissions in between 5% and 28% of referral letters according to the category of information. Thirteen per cent of the new patient referrals were assessed by specialists to be inappropriate and 4% of patients had been referred to an inappropriate specialty. Significantly more of the referrals to medical specialties were inappropriate (20%) than to surgical specialties (9%) (P < 0.01). There were more than three times the number of errors and omissions in the referral letters of referrals assessed as inappropriate than in the referral letters of referrals assessed as appropriate (P < 0.01). The referral letters of referrals assessed as inappropriate were more than nine times as likely to omit the reasons for or objectives of the referral compared with letters for those referrals assessed as appropriate (P < 0.01). There was a good overall agreement between the specialists and general practitioner in their assessment of the appropriateness of the clinical referrals (kappa = 0.614, P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Do clinical guidelines improve general practice management and referral of infertile couples

Abstract: OBJECTIVE--To evaluate guidelines for general practice management and referral of infertile couples. Guidelines were implemented with a disease specific reminder at the time of consultation (the guidelines were embedded within a structured infertility management sheet for each couple). DESIGN--Pragmatic randomised controlled trial. Participating practices were randomised to a group that received the guidelines and a control group. SETTING--82 general practices in Grampian region. SUBJECTS--100 couples referred by general practitioners receiving the guideline and 100 couples referred by control general practitioners. MAIN OUTCOME MEASURES--Whether the general practitioner had taken a full sexual history and examined and investigated both partners appropriately. RESULTS--Characteristics of patients referred by study and control general practitioners did not differ significantly at baseline. Compliance with the guidelines increased for all targeted activities. General practitioners in the study group were more likely to take a sexual history (for example, couples9 use of fertile period, 85% v 69%, p 0.05). Improvements were greater when general practitioners used the disease specific reminder. CONCLUSION--Receiving guidelines led to improvements in the process of care of infertile couples within general practice. This effect was enhanced when the guidelines were embedded in a structured infertility management sheet for each couple.

Influences on Teacher Referral of Children to Mental Health Services Gender, Severity, and Internalizing Versus Externalizing Problems

Abstract: Sixty-four third-, fourth-, and fifth-grade teachers read vignettes describing boys and girls with (1) externalizing and internalizing disorders and (2) externalizing and internalizing problems of less severity. Teachers rated whether the child described in each vignette needed to be referred for mental health treatment and indicated whether they had referred a similar child for treatment. Teachers' ratings of need for referral did not differ for boys and girls, and there was no gender effect on rhe teachers' reported referral experience. However, teachers reported having referred more children with externalizing problems than with internalizing problems for treatment, even though they did not rate externalizing problems as needing referral more than internalizing problems. Such discrepancies are discussed in terms of the different effect of internalizing and externalizing problems on the classroom environment.

Effect of NHS reforms on general practitioners' referral patterns.

Abstract: OBJECTIVE--To compare outpatient referral patterns in fundholding and non-fundholding practices before and after the implementation of the NHS reforms in April 1991. DESIGN--Prospective collection of data on general practitioners9 referrals to specialist outpatient clinics between June 1990 and March 1992 and detailed comparison of two time periods: October 1990 to March 1991 (phase 1) and October 1991 to March 1992 (phase 2). SETTING--10 fundholding practices and six non-fundholding practices in the Oxford region. SUBJECTS--Patients referred to consultant outpatient clinics. RESULTS--After implementation of the NHS reforms there was no change in the proportion of referrals from the two groups of practices which crossed district boundaries. Both groups of practices increased their referral rates in phase 2 of the study, the fundholders from 107.3 per 1000 patients per annum (95% confidence interval 106 to 109) to 111.4 (110 to 113) and the non-fundholders from 95.0 (93 to 97) to 112.0 (110 to 114). In phase 2 there was no difference in overall standardised referral rates between fundholders and non-fundholders. Just over 20% of referrals went to private clinics in phase 1. By phase 2 this proportion had reduced by 2.2% (1.0% to 3.4%) among the fundholders and by 2.7% (1.2% to 4.2%) among the non-fundholders. CONCLUSIONS--Referral patterns among fundholders and non-fundholders were strikingly similar after the implementation of the NHS reforms. There was no evidence that fundholding was encouraging a shift from specialist to general practice care or that budgetary pressures were affecting general practitioners9 referral behaviour.

Referral bias in aneurysmal subarachnoid hemorrhage

Abstract: ✓ The objective of this study was to assess the effect of referral bias on survival in patients with subarachnoid hemorrhage (SAH). The characteristics of 49 patients with aneurysmal SAH from a single community were compared with those of 328 patients referred from outside the community, all treated in the same medical care setting. In addition, referral patients who received surgery were compared by differential survival analysis with those still awaiting surgery at Days 1 to 3, Days 4 to 10, and Days 11 to 15. There was a dramatic difference in the 30-day survival rate between referral patients (83%) and community patients (59%), but most of the difference had occurred by the 2nd day after SAH. In the referral patients, the variables present at first medical attention that were found to have an independent effect on survival were clinical grade, presence of coma, number of days from SAH to referral, diastolic blood pressure, and patient age. There was a higher survival rate at 1 year for patients who we...

Referral adherence in an inner city breast and cervical cancer screening program

Abstract: Background. Early detection and immediate follow-up treatment for cancer of the breast and cervix can reduce morbidity and mortality. This report describes adherence to follow-up appointments for suspected breast and cervical malignancies in a population of low-income black women who participated in a community-based nurse-managed screening program. Methods. Components of the program that were part of the intervention included the following: a consistent referral mechanism augmented by a computerized tickler system; education of women about the importance of follow-up; and active nurse assistance in the follow-up process. Referral for follow-up of suspected malignancies or for other questionable findings was made to the public sector hospital clinics (86%) or to other providers of the women's choice (14%). Results. Follow-up rates for suspected malignancies of the breast were high (92%) in this population of women, sometimes described as less likely to adhere to recommendations for continued care. In contrast, adherence rates for gynecologic conditions were lower (70%). Conclusions. This screening program and follow-up system has relevance to systems that serve similar groups of low-income women.

An outbreak of hepatitis A among health care workers: risk factors for transmission.

Abstract: OBJECTIVES. The purpose of this study was to investigate a nosocomial outbreak of hepatitis A that occurred in the burn treatment center of a referral hospital. METHODS. Retrospective cohort and case-control studies were performed to determine acquisition rates and risk factors for transmission. Adjusted infection rates were calculated by week of exposure. A case-control study was conducted to determine potential mechanisms for nosocomial acquisition. Recently infected health care workers were defined as case patients; exposed, serosusceptible health care workers without infection served as controls. RESULTS. The outbreak of hepatitis A affected 11 health care workers and 1 other burn patient (1 secondary patient case). All 11 health care workers became ill after the admission of a man and his 8-month-old son who developed hepatitis A while in the hospital. The cumulative incidence risk ratio was elevated for health care workers caring for either the infant or the father during the same week of exposure. ...

Analysis of referrals of mental health problems by general practitioners.

Abstract: The majority of people in the community who have a psychiatric disorder will consult their general practitioner. Referrals from general practice to specialist services are, however, relatively rare. The filter between primary care and specialist care has been characterized by Goldberg and Huxley as the least permeable of the filters separating psychiatrists and other specialists from the populations they serve. These referrals form the subject of this study in the Netherlands. Using a large database of doctor-patient contacts, the proportion of mental health disorders resulting in a referral and the characteristics of the patient and general practitioner that are involved in such a referral have been determined. In addition, the type of mental health institution or specialist to which referrals were directed and the characteristics influencing this choice were examined. Only 6% of patients presenting with a psychiatric disorder during surgery hours were referred to specialist care. Younger patients, male patients and patients with severe diagnoses had a greater probability of being referred. The percentage of patients referred was higher in urban areas than in rural areas. Doctors with a limited task perception regarding mental treatment tended to refer more often. Although the diagnosis did have some relationship with the institutions to which patients were referred (psychotic conditions to psychiatric services and social/material problems to social workers), the most prevalent diagnoses (neurotic conditions and relationship problems) seemed to be more or less randomly distributed over the various possibilities. Preferences appeared to be related to the existence of regular meetings between general practitioners and specialists and a positive evaluation by general practitioners of the institution concerned.

Patient use of treatment-related information received from the cancer information service

Abstract: This study explored patient information-seeking behavior and how such behavior might affect patient-physician interaction or health-care decisions. Telephone interviews were conducted with 257 patients with cancer and their relatives who called the National Cancer Institute's Cancer Information Service (CIS) and who received treatment-related information. Results indicated that these patients were generally very satisfied with communication from their treating physicians, had strong information needs, and preferred to participate in their treatment plans. They sought information from CIS just after diagnosis (49%) or during treatment (31%). Many of these patients (42%) discussed the CIS information with their physicians and 19% of these physicians sought more information or consulted a CIS referral. CIS referrals were contacted personally by 18% of patients. Stepwise discriminant analyses indicated that, compared with patients who did not, patients with either of these outcomes were more stressed by their disease and had been seen at more hospitals. Additionally, patients who shared CIS information with their physicians were also younger and more trusting that their physicians had current knowledge. Patients who themselves contacted a CIS referral were also more educated, had higher information needs, were less satisfied with the clarity of physicians' answers to their questions, called CIS earlier in their illness, and called specifically for a referral. Overall, these patients' most common information needs were for exploring all treatment options and being knowledgeable when discussing treatment plans with physicians. The information received from CIS satisfied these needs and was often communicated to their physicians.

Civilian triage in the intensive care unit: the ritual of the last bed.

Abstract: Objective To evaluate the numerous problems that exist when there is an acute shortage of trained critical care nurses, no triage officer is available or designated, there is no cooperation among intensive care units (ICUs) or alternative sites, or there is excessive political or financial pressure applied to maintain a referral practice or to fill all the beds, or limited ability to divert ambulances to other hospitals. The Joint Commission on Accreditation of Health Care organizations now mandates a written policy: "when patient load exceeds optimal operational capacity" (1992). Data sources/study selection Selected clinical, philosophical, and public policy literature on the subject of triage. DATA SYNTHESIS/DATA EXTRACTION: 1) An ICU medical director, designee, or supervisory nurse should be empowered as the gatekeeper/triage officer. 2) The basis for regulating admission, discharge, or triage from the special care unit should be medical suitability (from a utilitarian or egalitarian point of view). During high-level triage when all ICU patients are receiving active therapy, these decisions should override the individual primary physician-patient relationship. 3) The guidelines should follow the "congestive heart failure" treatment analogy: a) preload reduction: hold high-risk patients in the postanesthesia care unit or Emergency Room, postpone surgery, hold transfers in outlying ICUs; b) improve cardiac performance: increase efficiency and decrease workload per patient by performing fewer invasive procedures and transporting fewer patients for abdominal computed tomography scans; c) afterload reduction: keep unstable patients in the postanesthesia care unit, send sicker patients to intermediate care units, send "stable" ventilator-dependent patients to general medical/surgical units, and transfer or resolve issues regarding "hopeless" patients. Conclusions It is necessary to have public disclosure of the broader issues related to high-level triage. The first issue is recognition that there are periods of time when ICU capacity is exceeded or skilled critical care nurse availability is reduced. The next issue is the decision of who is best suited to make complex and dynamic triage decisions and what kind of oversight should be provided. Other issues relate to whether there should be patient or family consent, and what to do about patients receiving marginal benefit or who are considered hopeless or unsalvageable, yet the family or surrogate decision maker (or perhaps one of the consultants) wants to continue active care in the ICU. In the conflict between individual and community rights and benefits, there should be a nonlitigious approach when a patient is harmed during these periods of high census or limited capacity. In recognition of these complex issues (including potential conflicts among ICUs, hospital administration, individual physicians, and the various medical and surgical programs feeding patients into special care units), the Society of Critical Care Medicine has organized a Task Force on the legal and ethical justification for triage.

Problem Ownership, Causal Attributions, and Self-Efficacy as Predictors of Teachers' Referral Decisions

Abstract: Fifty-five elementary teachers were presented with 12 vignettes describing chronic, persistent classroom behavioral problems. Teachers were interviewed regarding their perceptions of the causes of students' problems, their control over the problem, their self-efficacy for resolving the problem on their own, and their choice of intervention: child referral, consultation, or handling the problem without assistance. Two series of discriminant function analyses (DFAs) were applied to determine how well intervention choice could be predicted by (a) ratings of the importance of six causal factors, or (b) teachers' perceptions of control over the problem and self-efficacy for resolving the problem. Seven of the 12 DFAs for the second function were significant, with self-efficacy consistently predicting teachers' choices to attempt to resolve the problem on their own rather than to seek assistance through consultation or referral. Generally, teachers' self-efficacy, perceptions of control, and attributions did no...

Clinicians and the coronial system: ability of clinicians to recognise reportable deaths.

Abstract: OBJECTIVE--To assess the ability of clinicians to recognise deaths which require referral to the coroner. DESIGN--Postal questionnaire consisting of 16 fictitious case histories, 14 of which contained a clear indication for referral to the coroner. SETTING--Large teaching hospital. Coroner9s office. SUBJECTS--200 clinicians from general medical and surgical firms and senior staff of the local coroner9s office (two coroner9s officers and the two deputy coroners). MAIN OUTCOME MEASURES--Number of correct assessments on questionnaire. RESULTS--The mean recognition score for the clinicians was 9.11 (range 3-14) with no difference between the clinical grades. All of the coroner9s senior staff recorded maximum recognition scores of 16. CONCLUSIONS--The study highlights several features of the coronial system which are poorly understood by clinicians and provides the basis for an initiative to improve the medicolegal education of all clinicians.

Non-attendance at outpatient clinics: is it related to the referral process?

Abstract: Non-attendance at outpatient clinics is a complex problem and previous studies have concentrated on hospital-related factors. It has been suggested that non-attendance might be related to the referral process, including the selection of patients for referral and the quality of communication between GP and patient. These issues are examined in a study of 1492 patients given first-time appointments at ENT and gastroenterology clinics. Non-attendance rates were 26 and 20% respectively. Non-attendance was not related to the nature, severity or duration of the patients' presenting problems at the time of referral or to their perception of the need for referral. Resolution of symptoms did not appear to be a major reason for non-attendance. Patients were significantly less likely to attend if they had been unable or only partly able to discuss their health problem with their general practitioner. Those who had requested referral were equally likely to default.

Development of a health education program for parents of preschool children with asthma

Abstract: This paper presents the development and pilot testing of a self-management education program for parents of preschool children (0-4 years) with asthma, involving general practitioners, asthma nurses, community nurses and doctors of child health centers. The program intends to integrate education in the medical care provided to the child (and the parent). The program contains four manuals, one for each group of health care providers, and a booklet for parents. The manuals identify the educational tasks per discipline and regulate referral from one discipline to another. The booklet provides written information for parents. In the development of the program, representative from both the target population and the providers of the education were involved in needs assessment surveys. Findings of these surveys were integrated into the design of the program. Then, a pilot study was conducted to test the efficacy of the program during group sessions. Findings indicate that the variables measured (knowledge, attitude, self-efficacy and self-management behaviors) improved significantly from pre- to post-test. Finally, the program was revised for the next phase in which the program will be evaluated in primary health care with a controlled trial.