Showing papers on "Referral published in 1998"

Influence of Patient Preferences and Local Health System Characteristics on the Place of Death

Abstract: OBJECTIVE: To examine the degree to which variation in place of death is explained by differences in the characteristics of patients, including preferences for dying at home, and by differences in the characteristics of local health systems. DESIGN: We drew on a clinically rich database to carry out a prospective study using data from the observational phase of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT component). We used administrative databases for the Medicare program to carry out a national cross-sectional analysis of Medicare enrollees place of death (Medicare component). SETTING: Five teaching hospitals (SUPPORT); All U.S. Hospital Referral Regions (Medicare). STUDY POPULATIONS: Patients dying after the enrollment hospitalization in the observational phase of SUPPORT for whom place of death and preferences were known. Medicare beneficiaries who died in 1992 or 1993. MAIN OUTCOME MEASURES: Place of death (hospital vs non-hospital). RESULTS: In SUPPORT, most patients expressed a preference for dying at home, yet most died in the hospital. The percent of SUPPORT patients dying in-hospital varied by greater than 2-fold across the five SUPPORT sites (29 to 66%). For Medicare beneficiaries, the percent dying in-hospital varied from 23 to 54% across U.S. Hospital Referral Regions (HRRs). In SUPPORT, variations in place of death across site were not explained by sociodemographic or clinical characteristics or patient preferences. Patient level (SUPPORT) and national cross-sectional (Medicare) multivariate models gave consistent results. The risk of in-hospital death was increased for residents of regions with greater hospital bed availability and use; the risk of in-hospital death was decreased in regions with greater nursing home and hospice availability and use. Measures of hospital bed availability and use were the most powerful predictors of place of death across HRRs. CONCLUSIONS: Whether people die in the hospital or not is powerfully influenced by characteristics of the local health system but not by patient preferences or other patient characteristics. These findings may explain the failure of the SUPPORT intervention to alter care patterns for seriously ill and dying patients. Reforming the care of dying patients may require modification of local resource availability and provider routines.

Explorations of National Culture and Word-of-Mouth Referral Behavior in the Purchase of Industrial Services in the United States and Japan

Abstract: In this study, the authors examine how national culture affects referral behavior for industrial services such as advertising, banking, and accounting. The authors collected data using interviews with managers of small- and medium-sized companies in the United States and Japan. The results show that national culture has a strong effect on the number of referral sources consulted and that Japanese companies use more than comparable American companies do. Don't laugh, but all the really important [business] services I have, I found in the Yellow Pages (American manager of a small manufacturing company in the United States). When starting a new business, your bank means everything. Just about all my service vendors came from talking with my bank (Japanese owner of a cosmetics manufacturer in Tokyo).

Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial

Abstract: Objective To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse events and the management of calls. Design Block randomised controlled trial over a year of 156 matched pairs of days and weekends in 26 blocks. One of each matched pair was randomised to receive the intervention. Setting One 55 member general practice cooperative serving 97 000 registered patients in Wiltshire. Subjects All patients contacting the out of hours service or about whom contact was made during specified times over the trial year. Intervention A nurse telephone consultation service integrated within a general practice cooperative. The out of hours period was 6 15 pm to 11 15 pm from Monday to Friday, 11 00 am to 11 15 pm on Saturday, and 8 00 am to 11 15 pm on Sunday. Experienced and specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advice; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral to the emergency service or advice to attend accident and emergency. Calls were managed with the help of decision support

Comparing generalist and specialty care: discrepancies, deficiencies, and excesses.

Abstract: Policymakers, managed care organizations, medical educators, and the general public are showing an increasing interest in the amount and quality of care provided by generalists and subspecialists This article reviews studies comparing the knowledge base of and quality of care provided by these 2 groups of physicians English-language articles were identified through MEDLINE (1966-present) using the following keywords: generalist, generalism, (sub)specialist, (sub)specialty, (sub)specialization, consultation, referral, and quality of care, and through the bibliographies of these citations All studies were evaluated With respect to quality of care, only American studies were chosen Data quality was assessed by me Evidence is strongest that the knowledge base and quality of care provided by specialists exceeds those of generalists for certain conditions such as myocardial infarction, depression, and acquired immunodeficiency syndrome Differences in many other areas are multifactorial, and often a function of study design or patient selection The differences, however, are not as striking or important to the health of the public at large as those deficiencies in disease management, preventive care, and health maintenance that are common to all physicians Furthermore, overuse of diagnostic and therapeutic modalities by certain specialists leads to increased costs with either no benefit or added risks to patients The quality and coordination of care provided by generalists and specialists may be improved through changes in education and training, via quality improvement methods of providing patient care, and by increasing visit length and optimizing use of referrals and strategies for generalist-specialist comanagement Further study of these areas is warranted and should concentrate on outcomes

Severity distribution of atopic dermatitis in the community and its relationship to secondary referral

Abstract: Although atopic dermatitis is the most common inflammatory dermatosis affecting children, no previous studies have evaluated the relationship between disease severity and the referral pattern to secondary health care services. We carried out a cross-sectional survey of 1760 children aged 1-5 years selected from the age-sex registers of four urban and semiurban general practices in Nottingham. Atopic dermatitis was diagnosed by a dermatologist on the basis of symptoms and signs of a flexural itchy rash that had been present in the previous 12 months. The severity of atopic dermatitis was assessed clinically by the same dermatologist on the basis of reported symptoms over the previous 12 months and clinical signs, and was graded on a three-point scale as mild, moderate or severe. Information on the use of primary and secondary health care services was recorded at the time of the interview. The 1-year period prevalence of atopic dermatitis was 16.5% (95% confidence interval 14.7-18.2%). The severity distribution of atopic dermatitis was: mild 84% (n = 242), moderate 14% (n = 41) and severe 2% (n = 7). Of those children with atopic dermatitis, 96% (n = 278) had consulted their general practitioner in the previous 12 months and 6% (n = 17) had been seen in secondary care. Overall, 4% (n = 11) of those children with atopic dermatitis had a consultation with a dermatologist. Other sources of secondary care referral included the paediatric department (n = 2) and accident and emergency department (n = 6). Referral to secondary care was found to be positively related to disease severity, with referral occurring in 3% of mild cases, 15% of moderate cases and 43% of severe cases. Although the relative referral rate of mild and moderately severe disease was low, these cases were found to represent a significant proportion (82%) of the total numbers of children seen in secondary care. This study has shown that: (i) most cases of atopic dermatitis in the community are mild in severity; (ii) referral to secondary health care services by general practitioners is infrequent; (iii) disease severity is an important determinant of referral to secondary care; and (iv) any potential change in the referral pattern of mild/moderate cases of atopic dermatitis to secondary care is likely to produce a significant increase in workload for dermatology departments.

Child Fatalities From Religion-motivated Medical Neglect

Abstract: Objective To evaluate deaths of children from families in which faith healing was practiced in lieu of medical care and to determine if such deaths were preventable Design Cases of child fatality in faith-healing sects were reviewed Probability of survival for each was then estimated based on expected survival rates for children with similar disorders who receive medical care Participants One hundred seventy-two children who died between 1975 and 1995 and were identified by referral or record search Criteria for inclusion were evidence that parents withheld medical care because of reliance on religious rituals and documentation sufficient to determine the cause of death Results One hundred forty fatalities were from conditions for which survival rates with medical care would have exceeded 90% Eighteen more had expected survival rates of >50% All but 3 of the remainder would likely have had some benefit from clinical help Conclusions When faith healing is used to the exclusion of medical treatment, the number of preventable child fatalities and the associated suffering are substantial and warrant public concern Existing laws may be inadequate to protect children from this form of medical neglect

Impact of a Medicaid Primary Care Provider and Preventive Care on Pediatric Hospitalization

Abstract: Objective. This study evaluates the impact that a Medicaid managed care program had on avoidable hospitalization, a form of health care misuse that we hypothesize can be reduced by improved access to and quality of primary care in the context of a managed care program. Ambulatory care sensitive (ACS) hospitalizations, a previously defined categorization of hospitalization, as well as all pediatric hospitalizations were also studied. Intervention. The Maryland Access to Care (MAC) was a fee-for-service, gatekeeper, Medicaid managed care program with assigned primary medical providers and required Early Periodic Screening, Diagnosis, and Treatment (EPSDT) examinations. Medicaid managed care elements include: 1) assignment to primary medical provider (PMP) either by voluntary choice or mandatory enrollment of eligible Aid to Families With Dependent Children (AFDC), Medical Assistance (medical needy), and Supplemental Security Income; 2) a medical home accessible 24 hours a day, 7 days a week; 2) PMP must authorize emergency department (ED), inpatient, and specialty care but there were no disincentives to PMP for referral; 3) fee-for-services reimbursement (with a physician rate increase) for primary care, authorized specialist care, and hospitalization; and 4) an on-line eligibility verification system was available to all medical providers. Pre-enrollment as well as publicity allowed MAC to be phased in rapidly, resulting in 70% to 80% enrollment by the end of the first program year. Design. The design of this study is that of a pre- and postevaluation of the MAC program using Medicaid claims analysis of data 3 years pre-MAC and 2 years post-MAC. In multivariate analyses, this study also compares MAC-enrolled children to non–MAC-enrolled children (before and after MAC began) to estimate the impact of MAC enrollment while controlling for potential confounders. Setting. State of Maryland from 1989 to 1993. Patients. MAC-eligible children ≤18 years of age. Outcome Measures. Claims data were used to define avoidable hospitalization (based on ambulatory care received before hospitalization), to define ACS hospitalizations (based on the International Classification of Diseases–Clinical Modification, Ninth Revision [ICD-9-CM] codes), and to summarize use of ambulatory and inpatient care. Avoidable hospitalizations include those conditions for which evidence exists that specific ambulatory care modalities reduce hospitalization rates. These hospitalizations were defined by combining the first ICD-9-CM on an inpatient claim with ambulatory and/or pharmacy claims for services before that hospitalization. The criterion of preceding ambulatory care was applied by linking dates of admission to hospital with ambulatory service dates. An example of an avoidable hospitalization is a hospitalization for asthma (ICD-9-CM = 493) that has no antecedent pharmacy claim for steroids. ACS hospitalizations have been defined as those conditions for which timely and effective primary care can help to reduce the risk of hospitalizations. These are based solely on ICD-9-CM discharge codes that were studied by Billings and Teicholz 11 in 1990 and used by an Institute of Medicine report 12 in 1993. Examples include hospital discharge diagnoses of asthma (ICD-9-CM = 493), gastroenteritis (ICD-9-CM = 558.9), and dehydration (ICD-9-CM = 276.5). Usage measures, such as preventive care visits or ED visits, were created using Maryland Medicaid codes, Current Procedural Terminology codes, and ICD-9-CM codes. Linear regression was used to model trend. Logistic regression was used to model the probability of ambulatory and inpatient care given MAC enrollment and other covariates. First, logistic regression was used to predict the probability of any ambulatory care use among all MAC-eligible children during a quarter to model changes in access that may have occurred during MAC. Then, among users of ambulatory care or inpatient care, logistic regression was used to predict the probability of hospitalization. Results. Most of the children studied were in the AFDC program, about half were African-American, one third resided in Baltimore City, and 9% of children had ICD-9-CMs reflecting chronic disease. The mean percentage of time children were MAC-eligible per quarter was 91%. Only 5% of children were continuously enrolled for all 20 quarters included in this study. Per-capita ambulatory care visits, especially per-capita preventive care visits, increased significantly during the study period (b = 0.003) whereas per-capita ED visits did not change. The mean number of preventive visits was 0.2 visits/quarter for MAC-enrolled children compared with 0.1 visits/quarter for nonenrolled children. Although the mean number of ED visits was the same (0.06 visits/quarter) during the pre- and post-MAC periods, the mean number of ED visits for MAC-enrolled children was slightly higher than nonenrolled children (0.065 versus 0.057 visits per quarter). Because multiple factors affect use, multivariate analysis was used to adjust for potential confounders. With all 3.2 million child-quarter observations included in the regression, MAC enrollment (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 2.17–2.22) was strongly associated with the probability of any preventive care visits (1 or more). MAC enrollment was also associated with an increased probability of any ED use (OR = 1.4, 95% CI = 1.42–1.46) or any ambulatory care visit (OR = 2.58, 95% CI = 0.57–2.60). Among those children who used ambulatory care (1.2 million child-quarters), MAC enrollment was associated with a lower probability of avoidable (OR = 0.89, 95% CI = 0.83–0.97) and any hospitalization (OR = 0.81, 95% CI = 0.79–0.84), but no change in ACS hospitalization (OR = 0.96, 95% CI = 0.92–1.01). With multiple hospitalizations per quarter excluded, MAC enrollment was associated with a reduced probability of avoidable (OR = 0.86, 95% CI = 0.80–0.93), ACS (OR = 0.93, 95% CI = 0.88–0.98), and any pediatric hospitalization (OR = 0.79, 95% CI = 0.76–0.81). The probability of an avoidable hospitalization was inversely related to the number of preventive care visits (OR = 0.70, 95% CI = 0.67–0.74) and directly related to ED visits (OR = 2.11, 95% CI = 2.06–2.16). Conclusions. Enrollment in the MAC program and preventive care were associated with a reduced probability of avoidable as well as any pediatric hospitalization. Given the strong association between preventive care and reduced probability of hospitalization, it is likely that MAC exerts a positive effect on hospitalization through augmented preventive care, ie, numbers of preventive care visits, required EPSDT, increased access, and provider continuity. Further research is needed to document the clinical effectiveness of preventive care for children.

Gender Differences in ADHD

Abstract: This study examined possible gender differences in children and adults with attention-deficit/hyperactivity disorder. Results indicated that adult self-ratings differed significantly by gender. Adult women reported fewer assets and more problems than did male counterparts, but there was no gender difference with respect to age at referral, intelligence quotient, indicators of neuropsychological performance, or parent or teacher ratings of behavior. Referral bias against girls is a possible reason for previously reported gender differences, so we interpreted our results in light of the participants' referral patterns. There was a nonsignificant trend for girls with relatively more severe ratings of hyperactivity, conduct disorder, or inattention to be referred earlier than were boys. Overall, our results suggest no evidence of cognitive or neuropsychological differences by gender in samples that are sensitive to behavioral deviance in girls (as evidenced by early referral), but adult women's self-perception is comparatively poorer than that of adult men.

Nutrition practice guidelines for type 1 diabetes mellitus positively affect dietitian practices and patient outcomes

Abstract: Objectives Assess the acceptance and ease of use of Nutrition Practice Guidelines for Type 1 Diabetes Mellitus by dietitians in a variety of settings; determine if nutrition care activities of dietitians change when practice guidelines are available; measure changes in patient control of blood glucose level, measured as glycated hemoglobin (HbA 1c ); compare patient satisfaction with care and perceptions about quality of life. Design Using the approach of outcomes research, volunteer dietitians were recruited and assigned randomly to a usual care group or a practice guidelines group. Patients with type 1 diabetes were enrolled by dietitians and followed up for a 3-month period. Outcome measures included dietitian care activities, changes in patient HbA 1c levels, and patient satisfaction and perceptions about quality of life. Subjects/settings Dietitians from across the United States who responded to a recruitment notice participated. Their work settings included diabetes referral centers, endocrinology clinics, primary care and community health clinics, hospitals, and a worksite clinic. They recruited patients from their setting for the study. Outcome data were available from dietitians providing care to 24 patients using the new practice guidelines and dietitians providing care to 30 patients using more traditional methods. Statistical analysis χ 2 Test, t test, and analysis of covariance. Results Dietitians in the practice guidelines group spent 63% more time with patients and were more likely to do an assessment and discuss results with patients than dietitians in the usual care group. Practice guidelines dietitians paid greater attention to glycemic control goals. Levels of HbA 1c improved at 3 months in 21 (88%) of practice guidelines patients compared with 16 (53%) of usual care patients. Practice guidelines patients achieved greater reductions in HbA 1c level than usual care patients (−1.00 vs −0.33). This difference was statistically significant and clinically meaningful. Conclusions/applications Dietitians responded positively to practice guidelines for type 1 diabetes. Use of guidelines resulted in changes in dietitian practices and produced greater improvements in patient blood glucose outcomes at 3 months compared with usual care. Practice guidelines did not significantly influence patient satisfaction with care or perceived quality of life. J Am Diet Assoc. 1998;98:62-70 .

Management of common musculoskeletal problems: A survey of Ontario primary care physicians

Abstract: BACKGROUND: In Canada, primary care physicians manage most musculoskeletal problems. However, their training in this area is limited, and some aspects of management may be suboptimal. This study was conducted to examine primary care physicians9 management of 3 common musculoskeletal problems, ascertain the determinants of management and compare management with that recommended by a current practice panel. METHODS: A stratified computer-generated random sample of 798 Ontario members of the College of Family Physicians of Canada received a self-administered questionnaire by mail. Respondents selected various items in the management of 3 hypothetical patients: a 77-year-old woman with a shoulder problem, a 64-year-old man with osteoarthritis of the knee and a 30-year-old man with an acutely hot, swollen knee. Scores reflecting the proportion of recommended investigations, interventions and referrals selected for each scenario were calculated and examined for their association with physician and practice characteristics and physician attitudes. RESULTS: The response rate was 68.3% (529/775 eligible physicians). For the shoulder problem, all of the recommended items were chosen by the majority of respondents. However, of the items not recommended, ordering blood tests was selected by almost half (242 [45.7%]) as was prescribing an NSAID (236 [44.7%]). For the knee osteoarthritis the majority of respondents chose the recommended items except exercise (selected by only 175 [33.1%]). Of the items not recommended, tests were chosen by about half of the respondents and inappropriate referrals (chiefly for orthopedic surgery) were chosen by a quarter. For the acutely hot knee, the majority of physicians chose all of the recommended items except use of ice or heat (selected by only 188 [35.6%]). Although most (415 [78.5%]) of the respondents selected the recommended joint aspiration for this scenario, 84 (15.9%) omitted this investigation or referral to a specialist. The selection of recommended items was strongly associated with training in musculoskeletal specialties during medical school and residency. INTERPRETATION: Primary care physicians9 management of 3 common musculoskeletal problems was for the most part in accord with panel recommendations. However, the unnecessary use of diagnostic tests, inappropriate prescribing of NSAIDs, low use of patient-centred options such as exercise, and lack of diagnostic suspicion of infectious arthritis are cause for concern. The results point to the need for increased exposure to musculoskeletal problems during undergraduate and residency training and in continuing medical education.

Medical malpractice implications of alternative medicine

Abstract: Although use of alternative therapies in the United States is widespread and growing, little is known about the malpractice experience of practitioners who deliver these therapies or about the legal principles that govern the relationship between conventional and alternative medicine. Using data from malpractice insurers, we analyzed the claims experience of chiropractors, massage therapists, and acupuncturists for 1990 through 1996. We found that claims against these practitioners occurred less frequently and typically involved injury that was less severe than claims against physicians during the same period. Physicians who may be concerned about their own exposure to liability for referral of patients for alternative treatments can draw some comfort from these findings. However, liability for referral is possible in certain situations and should be taken seriously. Therefore, we review relevant legal principles and case law to understand how malpractice law is likely to develop in this area. We conclude by suggesting some questions for physicians to ask themselves before referring their patients to alternative medicine practitioners.

Referral and diagnosis of common rheumatic diseases by primary care physicians.

Abstract: SUMMARY Objective. To describe primary care patterns of referral and diagnoses of patients with rheumatic diseases referred to rheumatologists. Methods. The medical records of all consecutive patients referred in 1994 by >300 primary care physicians to two rheumatologists at an academic centre were reviewed. The referring physician diagnosis was compared with the rheumatologist’s diagnosis. Sensitivity, specificity and predictive values of primary care diagnoses were estimated using the rheumatologist diagnosis as the ‘gold standard’. Setting. University-based rheumatology out-patient clinic. Results. Over half of the patients referred had a rheumatologist diagnosis of soft-tissue rheumatism or a spinal pain syndrome. Three hundred and forty-seven patients (49%) had a primary care diagnosis of a defined rheumatic disease. Of these, 142 (41%) of the primary care diagnoses were subsequently modified by the rheumatologist. The highest agreement between primary care physician and rheumatologist was observed for crystal-induced arthritis (k= 0.86), and the lowest agreement for polymyalgia rheumatica (k= 0.39) and systemic lupus (k= 0.46). Sensitivity was lowest for a primary care diagnosis of fibromyalgia (48%) and highest for ankylosing spondylitis (94%). Positive predictive values were generally low, in particular for systemic lupus erythematosus (33%) and polymyalgia rheumatica (30%). Conclusion. Most patients referred to an academic rheumatology centre had soft-tissue rheumatism or other pain syndromes. In general, diagnostic agreement between rheumatologists and primary care physicians was low. Increased emphasis on musculoskeletal disorders should be encouraged in medical education to increase the eYciency of rheumatology referrals. Rheumatic diseases comprise >100 diVerent entities ary care and non-specialist physicians were registered with varying clinical characteristics, prognosis and with the College of Physicians and Surgeons of Alberta, therapy requirements. It has been estimated that about half of them in Northern Alberta. The medical rheumatic diseases aVect ~10% of the population [1]. records of these patients were reviewed to determine Most frequently, the initial contact of a rheumatic the referring diagnosis by the primary care physician patient is with a primary care physician, and >10% and the rheumatologist, diagnosis both at the initial of visits to primary care physicians are related to consultation and during follow-up. Diagnoses were rheumatic diseases [2]. An early diagnosis can facilitate grouped in broad categories including: (a) systemic the choice of adequate therapies and rationalize refer- lupus erythematosus (SLE); (b) rheumatoid arthritis rals to specialists. Inappropriate diagnosis can result (RA) and related arthritis ( juvenile chronic arthritis, in delays in treatment, inadequate prescription of ther- palindromic rheumatism; (c) spondyloarthropathies; apies, ‘labelling’ of patients with false-positive diag- (d ) polymyalgia rheumatica; (e) other connective tissue noses, and ineYcient use of resources (e.g. additional diseases; (f ) localized soft-tissue rheumatism; (g) testing or unnecessary referrals). The objective of this fibromyalgia; (h) entrapment neuropathies; (i) low study was to describe the patterns of primary care back pain and/or cervical pain; ( j) osteoarthritis and referrals to rheumatologists and to evaluate the accur- other localized osteoarticular syndromes; (k) crystalacy in the referral diagnoses of common rheumatic induced arthritis; ( l ) miscellaneous (other rheumatic diseases. diseases, diseases primarily from other systems). Patients with other miscellaneous diseases were

A preliminary study of the effects of early intervention with people with dementia and their families in a memory clinic

Abstract: A brief individualized intervention comprising of information about diagnosis and prognosis, reinforcement of coping strategies, crisis prevention advice and memory management programmes was offered to newly diagnosed people with dementia and their families, prior to referral to the services of their local psychogeriatric community support team. The control group received diagnosis and written advice and were referred directly to their local psychogeriatric community support team. At 18-month follow-up, improvements were found in the memory scores of the experimental group. Carer wellbeing was worse in the control group and this was associated with an increased likelihood of the breakdown of home care. We suggest that psychosocial variables may be important at the time of diagnosis and note an interesting relationship between memory ability in people with dementia and carer strain. Our results can only be fully understood in the context of methodological improvements. These are outlined, for the purpose o...

The recognition and treatment of depression in older people in primary care

Abstract: Objectives. To examine general practitioners' (GP) awareness of depression in their elderly patients (aged over 65) and to identify characteristics of those patients least likely to be recognized and treated. Design. A cross-sectional study comparing the clinical opinion of the GP with assessment of mental state using a validated interview schedule (the Short Comprehensive Assessment and Referral Evaluation). Setting and subjects. 510 elderly residents in the Gospel Oak area of Camden in North London registered with 28 GPs at 13 practices. Main outcome measures. Agreement between GP view and patient interview. Evidence of active management measured by examining GP records for appointments, referrals and prescription of psychotropic mediation. Results. GPs were aware of depression in 36 (51%) of 70 depressed patients. Those least likely to be recognized were men, the married, those with high levels of physical handicap, those suffering from visual impairment and those who were least well educated. Of the 32 patients believed to be depressed, 12 (38%) were prescribed antidepressant medication and/or referred to mental health/social services. Conclusions. Levels of recognition of depression were lower than other recent reports. These findings may reflect the continued debate about the most suitable management of the elderly depressed in primary care and stress the need for further evaluation of appropriate treatment strategies for this group. © 1998 John Wiley & Sons, Ltd.

Mental Health Service Use Among Young Children Receiving Pediatric Primary Care

Abstract: Objective To investigate the factors associated with mental health service use among young children. Method Five hundred ten preschool children aged 2 through 5 years were enrolled through 68 primary care physicians, with 388 (76% of the original sample) participating in a second wave of data collection, 12 to 40 months later. Consensus DSM-III-R diagnoses were assigned using best-estimate procedures. The test battery included the Child Behavior Checklist, a developmental evaluation, the Rochester Adaptive Etehavior Inventory, and a videotaped play session (preschool children) or structured interviews (older children). At wave 2, mothers completed a survey of mental health services their child had received. Results In logistic regression models, older children, children with a wave 1 DSM-III-R diagnosis, children with more total behavior problems and family conflict, and children receiving a pediatric referral were more likely to receive mental health services. Among children with a DSM-III-R diagnosis, more mental health services were received by children who were older, white, more impaired, experiencing more family conflict, and referred by a pediatrician. Conclusions Young children with more impairment and family conflict are more likely to enter into treatment. Services among young children of different races with diagnoses are not equally distributed. Pediatric referral is an important predictor of service use.

Linking Inpatients With Schizophrenia to Outpatient Care

Abstract: OBJECTIVE: This study focused on inpatients with schizophrenia or schizoaffective disorder who were scheduled to begin outpatient care with clinicians who had not previously treated them. The authors evaluated the effects of communication between the patients and their outpatient clinicians before discharge on patients' referral compliance, psychiatric symptoms, and community function at follow-up three months after discharge. METHODS: A total of 104 adult inpatients with schizophrenia or schizoaffective disorder who were scheduled to receive outpatient care from clinicians who had not previously treated them were evaluated at hospital discharge and again three months later. Comparisons were made between patients who had telephone or face-to-face contact with an outpatient clinician before hospital discharge and patients who did not have such contact. RESULTS: About half (51 percent) of the inpatient sample communicated with an outpatient clinician before leaving the hospital. Compared with patients who h...

Drug abuse treatment success among needle exchange participants.

Abstract: OBJECTIVE: Although lowering incidence rates of human immunodeficiency virus (HIV) transmission is the primary goal of needle exchange programs (NEPs), other desirable outcomes are possible. Referring exchange participants to more comprehensive drug abuse treatment programs has the potential to reduce or eliminate the use of drugs. This possibility was evaluated by comparing the treatment responses of new admissions with an outpatient opioid agonist treatment program in Baltimore, Maryland. METHODS: New admissions (1994 - 1997) to an opioid agonist treatment program were first grouped by referral source (needle exchange, n = 82 vs. standard referrals, n = 243) and then compared on admission demographic and clinical variables and response to treatment during the first three months. Outcome measures included retention rates, self-reported drug use and injecting frequencies, self-reported illegal activities for profit, and results from weekly urinalysis testing for opioids and cocaine. RESULTS: Patients from the NEP were significantly older and more likely to be male, African American, and unemployed than standard referral patients. Needle exchange patients also had a greater baseline severity of drug use than patients in the standard referral group. Despite these baseline differences, both groups achieved comparably good short-term treatment outcomes (including reduced drug use and criminal activity for profit); treatment retention was also good, although slightly better in the standard referral group (88% vs. 76%). CONCLUSION: These data demonstrate the feasibility and merits of creating strong linkages between NEPs and more comprehensive drug abuse treatment clinics.

Effectiveness of patient delivered partner medication for preventing recurrent Chlamydia trachomatis.

Abstract: OBJECTIVE: To determine if providing Chlamydia trachomatis infected women with medication to deliver to their sex partner(s) could reduce recurrent chlamydia infections compared with the standard partner referral method. STUDY DESIGN: A observational cohort study of 178 women, 14-39 years old attending a family planning clinic, diagnosed and treated for C trachomatis between October 1993 and December 1994 was conducted (43 received patient delivered partner medication (PDPM) and 135 received partner referral cards). Women were retested before or at their annual visit. RESULTS: The mean time of follow up was 17.7 months (SD 7.7). The PDPM group (n = 43) was similar to partner referral group (n = 135) for age, race, contraceptive method, history of an STD, and follow up time. The annual recurrent infection rate was lower among the PDPM group compared with the partner referral group (11.5% v 25.5%, p < 0.05). After adjusting for age in logistic regression, women in the PDPM group were less likely than women in the partner referral group to have an incident C trachomatis infection (OR 0.37, 95% CI 0.15-0.97, p < 0.05). CONCLUSION: These findings suggest that patient delivered partner medication can protect women from recurrent C trachomatis infection compared with the standard partner referral approach. Prospective studies with larger sample sizes are under way.

Psychological practice in primary care settings: Practical tips for clinicians.

Abstract: Many psychologists are finding new opportunities for practice in primary care settings. These settings challenge many aspects of traditional practice and require adaptation and innovation. Psychologists must consider changes in their site of practice, treatment duration, type of intervention, and role as part of a health care team. This article describes the culture of primary care medicine and offers 10 practical tips for the adaptation of psychological practice to primary care. Primary care is now the linchpin of the new health care delivery system. This focus on primary care creates both threats to the conventional independent practice of psychology and new opportunities for collaboration and direct participation in the delivery of primary care services. In terms of threat, a psychologist whose solo or small-group practice has focused predominately on private, office-based psychological assessment and psychotherapy faces increasing economic pressures created by market-driven reforms, managed care, and other limits to traditional fee-for-service psychological services (Frank & VandenBos, 1994). Managed care systems increasingly rely on primary care providers (including physicians in family n'~edicine, general internal medicine, pediatrics, and sometimes obstetricsgynecology) to screen and triage patients with a wide range of medical and psychological problems. These physicians are the gatekeepers for referral to all specialists, including psychologists. In terms of opportunity, psychologists who shift their practices to work closely with these providers as part of an integrated delivery system are most likely to continue to deliver services to a wide variety of patients (Shortell, Gillies, & Anderson, 1994).

Do hospital palliative care teams improve symptom control? Use of a modified STAS as an evaluation tool.

Abstract: The support team assessment schedule (STAS) has previously been validated as an evaluation tool for community palliative care teams and inpatient units. This study reports on use of an expanded STAS (E-STAS) to determine symptom prevalence and outcome for inpatients and outpatients referred to a multiprofessional hospital palliative care team. E-STAS forms were completed on patients at referral and twice weekly thereafter. Between August 1996 and May 1997, 352 patients had one or more E-STAS forms completed; 122 of this group had three or more assessments. One-hundred-and-eighty-two patients were male and 170 were female, the median age was 68.5 years (range 26-101 years) and all but 27 (8%) had malignant disease. Of the symptoms assessed on referral, the most common were psychological distress 93%, anorexia 73%, pain 59%, mouth discomfort 59%, depression 40%, constipation 36%, breathlessness 32%, nausea 24% and vomiting 13%. In the 122 patients where three or more assessment were completed, statistically significant improvements from first to last assessment were seen in all symptoms except depression. This study suggests that E-STAS may be a useful tool to evaluate interventions by a hospital palliative care team in patients with advanced disease.

Health Care Utilization by Children With Chronic Illnesses: A Comparison of Medicaid and Employer-insured Managed Care

Abstract: Objectives. This study compared utilization of health care services by children with chronic conditions who were insured by either Medicaid or an employer group in 1992 and 1993. Five chronic conditions were selected to illustrate patterns of service use: asthma, attention deficit disorder, diabetes, epilepsy, and sickle cell anemia. Methodology. Administrative databases were used to develop estimates of health services utilization for children t tests were used to compare service use rates between Medicaid and employer-insured populations. Results. A total of 8668 children across all health plan groups had at least one of the selected conditions. Because Medicaid enrolled-children tended to be younger, analyses were adjusted for age. In both systems, a greater percentage of Medicaid children had these five study conditions (5%) compared with employer-insured children (3%), suggesting that the Medicaid population was sicker. Mean length of enrollment during the 2-year study was longer for children in employer-insured programs. Children with chronic conditions enrolled in Medicaid managed care generally used services at a higher rate compared with children with similar conditions enrolled in employer-insured managed care. The extent of the increased use varied by condition, by service type, and by plan. Children with any of the chronic conditions studied had from 2 to almost 5 times more ED visits if they were enrolled in Medicaid than if they were enrolled in employer-based managed care, depending on the specific condition. In one of the two plans, Medicaid-enrolled children had more outpatient services, laboratory services, and radiography services than their counterparts in employer-based managed care. The same pattern of use was found for home health services (except for children with diabetes) and for office visits (except for children with sickle cell). The results show higher use of all services by children with asthma and diabetes in Medicaid managed care compared with employer-based managed care. In contrast, the pattern is mixed for children with epilepsy and sickle cell. The sample size of children with these conditions was smaller than with the three other conditions, which may account, in part, for a varied pattern of results. The pattern of use for attention deficit hyperactivity disorder (ADHD) was generally different from the other conditions. Children with ADHD in employer-based managed care had more hospital admissions, hospital days, and office visits than their counterparts in Medicaid managed care. In contrast, Medicaid-enrolled children with ADHD had more ED visits, laboratory services, outpatient hospital visits, and radiography services. Other than ED visits, the differences in service use between Medicaid and employer-insured children with ADHD were minimal. Of note, the pattern for ADHD is the same for most services for Plans A and B (excluding home health visits). This utilization pattern may reflect service use for comorbid conditions. Part of this difference may be explained by differences in Medicaid eligibility criteria used by the two plans. Medicaid eligibility regarding level of poverty was more stringent in Plan A than in Plan B. Plan A showed consistently high service utilization for Medicaid children compared with employer-insured children; Plan B showed less consistency. There are several patterns of utilization common to all disease and insurance groups. The majority of care seems to be delivered in physicians9 offices, rather than in other locations. When comparing the differences by disease categories, asthma shows more statistically significant differences in utilization between Medicaid and commercially-insured children than the other conditions. Asthma is the most prevalent condition of these five, which increases the power to detect statistical significance for this defined population. These results show the importance of evaluating conditions other than asthma, because utilization comparisons for different services may vary depending on the condition studied. Conclusion. This study of children with selected chronic health conditions indicates that: 1) a higher percentage of children enrolled in Medicaid managed care (5%) have these conditions compared with children enrolled in employer-insured managed care programs (3%); 2) on average, children with chronic health conditions who are enrolled in Medicaid managed care use more services than children with similar conditions who are insured through employers; and 3) although utilization rates are generally higher for children enrolled in Medicaid managed care than for children enrolled in employer-based managed care, the differences in rates vary greatly by service, by diagnosis, and by plan. Differences between the children enrolled in Medicaid and children enrolled in employer-based programs were more pronounced in one of the plans we studied compared with the other. Children with chronic conditions in Medicaid managed care have substantially different patterns of service use compared with children with similar conditions in employer-based managed care. This finding has major implications for policy development related to legislative proposals regarding referral practices, quality assurance, and capitation rates. Our results demonstrate the importance of examining a broad spectrum of chronic conditions and services when comparing Medicaid to employer-insured children with special needs. Utilization of several services, including ED, was higher for Medicaid children than for employer-insured children. Further analysis is recommended that controls for breadth-of-benefit package, severity of illness, and age. Also, differences across plans suggest that research at more than one site is critical for comprehensive policy analyses.