Showing papers on "Referral published in 2000"

The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people.

Abstract: OBJECTIVES: (1) To present the Behavioral Model for Vulnerable Populations, a major revision of a leading model of access to care that is particularly applicable to vulnerable populations; and (2) to test the model in a prospective study designed to define and determine predictors of the course of health services utilization and physical health outcomes within one vulnerable population: homeless adults. We paid particular attention to the effects of mental health, substance use, residential history, competing needs, and victimization. METHODS: A community-based probability sample of 363 homeless individuals was interviewed and examined for four study conditions (high blood pressure, functional vision impairment, skin/leg/foot problems, and tuberculosis skin test positivity). Persons with at least one study condition were followed longitudinally for up to eight months. PRINCIPAL FINDINGS: Homeless adults had high rates of functional vision impairment (37 percent), skin/leg/foot problems (36 percent), and TB skin test positivity (31 percent), but a rate of high blood pressure similar to that of the general population (14 percent). Utilization was high for high blood pressure (81 percent) and TB skin test positivity (78 percent), but lower for vision impairment (33 percent) and skin/leg/foot problems (44 percent). Health status for high blood pressure, vision impairment, and skin/leg/foot problems improved over time. In general, more severe homeless status, mental health problems, and substance abuse did not deter homeless individuals from obtaining care. Better health outcomes were predicted by a variety of variables, most notably having a community clinic or private physician as a regular source of care. Generally, use of currently available services did not affect health outcomes. CONCLUSIONS: Homeless persons are willing to obtain care if they believe it is important. Our findings suggest that case identification and referral for physical health care can be successfully accomplished among homeless persons and can occur concurrently with successful efforts to help them find permanent housing, alleviate their mental illness, and abstain from substance abuse.

The Child Behavior Checklist and Related Forms for Assessing Behavioral/Emotional Problems and Competencies

Abstract: 1. Thomas M. Achenbach, PhD* 2. Thomas M. Ruffle, MD† 1. 2. *Departments of Psychiatry and Psychology, University of Vermont, Burlington, VT. 3. 4. †Vermont Child Development Clinic, Burlington, VT. After completing this article, readers should be able to: 1. List the types of behavioral and emotional problems that primary care physicians who work with children must address. 2. Describe the data required from parents, children, teachers, and child care practitioners for assessment of behavioral and emotional problems. 3. Describe systems of questionnaires that can be used for obtaining standardized assessment data. Primary care physicians who work with children must deal with a great variety of behavioral and emotional problems. The system described in this article provides low-cost, standardized assessment and documentation of such problems and requires little effort by the physician. Primary care physicians are under increasing pressure to obtain standardized documentation for the conditions they encounter. The most obvious pressures stem from managed care. Among the most frequently imposed expectations of primary care physicians are to: Be gatekeepers for most forms of care needed by patients. Offer increasingly diverse services to more patients while limiting the time spent with each patient. Provide extensive documentation for assessments of patients and for treatment and referral. To fulfill these expectations, physicians need cost-effective procedures for obtaining, using, and transmitting information about patients. Children’s behavioral and emotional problems pose special challenges for meeting such managed care requirements. Certain types of behavioral problems, such as those ascribed to attention deficit hyperactivity disorder (ADHD), are widely publicized as candidates for medical management. Concerned parents, therefore, may request that pediatricians and family practitioners evaluate their children for ADHD. To assess ADHD and other behavioral and emotional problems, physicians need information from people who see children in their everyday contexts. Parents and parent-surrogates are the primary sources of such information for most children. Older children can contribute useful information about their own functioning. Teachers are especially important sources of information when children’s functioning in school is relevant, such as …

Communication Breakdown in the Outpatient Referral Process

Abstract: OBJECTIVE: To evaluate primary care and specialist physicians’ satisfaction with interphysician communication and to identify the major problems in the current referral process. DESIGN: Surveys were mailed to providers to determine satisfaction with the referral process; then patient-specific surveys were e-mailed to this group to obtain real-time referral information. SETTING: Academic tertiary care medical center. PARTICIPANTS: Attending-level primary care physicians (PCPs) and specialists. MEASUREMENTS AND MAIN RESULTS: The response rate for mail surveys for PCPs was 57% and for specialists was 51%. In the mail survey, 63% of PCPs and 35% of specialists were dissatisfied with the current referral process. Respondents felt that major problems with the current referral system were lack of timeliness of information and inadequate referral letter content. Information considered important by recipient groups was often not included in letters that were sent. The response rate for the referral specific e-mail surveys was 56% for PCPs and 53% for specialists. In this e-mail survey, 68% of specialists reported that they received no information from the PCP prior to specific referral visits, and 38% of these said that this information would have been helpful. In addition, four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists. CONCLUSIONS: Substantial problems were present in the referral process. The major issues were physician dissatisfaction, lack of timeliness, and inadequate content of interphysician communication. Information obtained from the general survey and referral-specific survey was congruent. Efforts to improve the referral system could improve both physician satisfaction and quality of patient care.

Guidelines for the prevention of falls in people over 65

Abstract: General practice p 994 Older people frequently fall. This is a serious public health problem, with a substantial impact on health and healthcare costs.1 These guidelines translate trial evidence about prevention of falls into recommendations that can be implemented in different settings, with the aim of reducing the rate of falls and injurious falls in people over 65 (see boxes 2 3). #### Summary points Multifaceted interventions reduce falls in older people (those over 65) Home assessment of older people at risk of falls without referral or direct intervention is not recommended Assessment of high risk residents in nursing homes with relevant referral is effective Evidence from well designed single trials shows that assessment and modification of risk factors of older people who have presented to an accident and emergency department after a fall and the provision of hip protectors in residents of nursing homes are effective We updated two previous systematic reviews to include any new evidence up to March 1998. 4 5 We electronically searched Medline for all randomised controlled trials and systematic reviews by using the terms fall(s), accidental falls, fracture, elderly, aged, older, and senior. We followed up relevant references in papers, and we contacted researchers in prevention of falls for information about other trial evidence and about studies from journals not catalogued by the National Library of Medicine. For inclusion, studies had to be randomised controlled trials of interventions designed to minimise or prevent exposure to the risk factors for falling (or fracture) in people aged 65 years or over living in either community or residential care. Outcomes had to include the number of people who had fallen or the number of falls or fractures. We excluded drug or dietary treatments for the prevention of fractures. Trials that fulfilled the inclusion criteria were reviewed and summarised …

Increasing Identification of Psychosocial Problems: 1979–1996

Abstract: Objective. To examine the changes in identification of pediatric psychosocial problems from 1979 to 1996. Research Design. Comparison of clinician-identified psychosocial problems and related risk factors among large primary care pediatric cohorts from 1979 (Monroe County Study) and 1996 (Child Behavior Study). Data were collected from clinician visit questionnaires developed originally for the 1979 study. Setting. Private practice offices of 425 community-based pediatricians and family practitioners across both studies. Patients. We enrolled all children from 4 to 15 years of age who presented for nonemergent services in primary care offices. The 1979 study included 9612 children seen by 30 clinicians and the 1996 study included 21 065 children seen by 395 clinicians. Selection Procedure. Each clinician enrolled consecutive eligible patients for both studies. Measurements and Results. From 1979 to 1996, clinician-identified psychosocial problems increased from 6.8% to 18.7% of all pediatric visits among 4- to 15-year-olds. We found increases in all categories of psychosocial problems, except for mental retardation. Attentional problems showed the greatest absolute increase (1.4%–9.2%) and emotional problems showed the greatest relative increase (.2%–3.6%). The use of psychotropic medications, counseling, and referral also increased substantially. In particular, the percentage of children with Attention deficit/hyperactivity problems receiving medications increased from 32% to 78%. These increases in psychosocial problems were associated with increases in the proportions of single-parent families and Medicaid enrollment from 1979 to 1996. Changes in clinician characteristics did not appear to be the source of increases in clinician diagnoses of psychosocial problems. Conclusions. Substantial increases in the identification of psychosocial problems in primary care paralleled demographic changes in children presenting to primary care offices and in the larger population.

Customer Referral Management: Optimal Reward Programs

Abstract: Sellers who plan to capitalize on the lifetime value of customers need to manage the sales potential from customer referrals proactively. To encourage existing customers to generate referrals, a seller can offer exceptional value to current customers through either excellent quality or a very attractive price. Rewards to customers for referring other customers can also encourage referrals. We investigate when referral rewards should be offered to motivate referrals and derive the optimal combination of reward and price that will lead to the most profitable referrals. We define a delighted customer as one who obtains a positive level of surplus above a threshold level and, consequently, recommends the product to another customer. We show that the use of referral rewards depends on how demanding consumers are before they are willing to recommend i.e., on the delight threshold level. The optimal mix of price and referral reward falls into three regions: 1 When customers are easy to delight, the optimal strategy is to lower the price below that of a seller who ignores the referral effect but not to offer rewards. 2 In an intermediate level of customer delight threshold, a seller should use a reward to complement a low-price strategy. As the delight threshold gets higher in this region, price should be higher and the rewards should be raised. 3 When the delight threshold is even higher, the seller should forsake the referral strategy all together. No rewards should be given, and price reverts back to that of a seller who ignores referrals. These results are consistent with the fact that referral rewards are not offered in all markets. Our analysis highlights the differences between lowering price and offering rewards as tools to motivate referrals. Lowering price is attractive because the seller "kills two birds with one stone": a lower price increases the probability of an initial purchase and the likelihood of referral. Unfortunately, a low price also creates a "free-riding" problem, because some customers benefit from the low price but do not refer other customers. Free riding becomes more severe with an increasing delight threshold; therefore, motivating referrals through low price is less attractive at high threshold levels. A referral reward helps to alleviate this problem, because of its "pay for performance" incentive only actual referrals are rewarded. Unfortunately, rewards can sometimes be given to customers who would have recommended anyway, causing a waste of company resources. The lower the delight threshold level, the bigger the waste and, therefore, motivating referrals through rewards loses attractiveness. Our theory highlights the advantage of using referral rewards in addition to lowering price to motivate referrals. It explains why referral programs are offered sometimes but not always and provides guidelines to managers on how to set the price and reward optimally.

The role of the pediatrician in the oral health of children: A national survey.

Abstract: Objectives. To assess pediatricians9 knowledge, attitudes, and professional experience regarding oral health, and to determine willingness to incorporate fluoride varnish into their practices. Background. Poor and minority children suffer disproportionately from dental caries and have limited access to dental care. In a recent analysis of national survey data, the General Accounting Office reported that poor children had 5 times more untreated decay than did children from higher income families. Untreated decay can lead to problems with eating, speaking, and attending to learning. Children who are poor suffer 12 times the number of restricted activity days because of dental problems, compared with more affluent children. Despite higher rates of dental decay, poor children had one half the number of dental visits compared with higher income children in 1996. Medicaid9s Early Periodic Screening Diagnosis and Treatment (EPSDT) program is intended to provide regular dental screenings and appropriate treatment but has apparently played a limited role in improving access to dental care for poor children. According to a report by the Office of the Inspector General of the Department of Health and Human Services, only 20% of children under 21 years of age, who were enrolled in Medicaid and eligible for EPSDT, actually received preventive dental services. By increasing their involvement in oral health prevention during well-child care visits, pediatricians may be able to play an important role in improving the dental health of their patients who have difficulty obtaining access to professional dental care. However, it is unclear to what degree pediatricians are knowledgeable about preventive oral health and the extent to which they may already be participating in prevention and assessment. Also, little is known about the incidence of dental problems in pediatric practice, and whether pediatricians perceive barriers to their patients9 receiving professional dental care. Finally, it is important to know how pediatricians value the promotion of oral health and whether they would be willing to take on additional activities aimed at its improvement. We addressed these questions in a national survey of pediatricians. Design. We surveyed a national sample of 1600 pediatricians randomly selected from the American Medical Association Master File to assess their knowledge, current practice, and opinion on their role in the promotion of oral health; experience with dental decay among patients and in referring patients for professional dental care; and willingness to apply fluoride varnish. Results. Of 1386 eligible survey recipients, 862 returned surveys for a response rate of 62%. Respondents reported seeing dental problems regularly. Two thirds of respondents observed caries in their school-aged patients at least once a month. Of the respondents, 55% reported difficulty achieving successful dental referrals for their uninsured patients and 38% reported difficulty referring their Medicaid patients. More than 90% of the respondents agreed that they had an important role in identifying dental problems and counseling families on the prevention of caries. Moreover, respondents were interested in increasing their involvement: 74% expressed a willingness to apply fluoride varnish in their practices. One half of the respondents, however, reported no previous training in dental health issues during medical school or residency, and only 9% correctly answered all 4 knowledge questions. Conclusion. Access to dental care and unmet dental health needs are serious, underaddressed problems for poor and minority children in the United States. In promoting preventive oral health, pediatricians benefit all children and particularly the underserved. We know of 2 states, Washington and North Carolina, that have acknowledged, through the provision of reimbursement, that pediatricians have a unique opportunity at well-child care visits to provide caries prevention counseling and care to poor children. Based on results of this survey, we believe it bodes well for expanding pediatrician involvement in oral health into other states. Specifically, we found that pediatricians overwhelmingly believe that they have an important role and are already involved in providing anticipatory guidance on oral health issues. However, lack of up-to-date information and knowledge as well as the difficulty pediatricians perceive in referring some patients for professional dental care call into question the current level of effectiveness of pediatricians in promoting oral health. We offer several recommendations to begin the dialogue on expanding the role of pediatricians in preventive oral health: 1. Pediatricians will require adequate training in oral health in medical school, residency, and in continuing education courses. We recommend adding a module on oral health and dental care to the undergraduate medical school physical examination skills courses and an oral health rotation to pediatric residency curriculums. Having dental professionals provide such instruction would enhance acquisition of hands-on skills and could encourage future professional collaboration and cross-referrals. 2. Pediatricians will require current information and guidelines on preventive dental care. With the exception ofBright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, very little is available to guide pediatricians in the promotion of oral health in their practices. The American Academy of Pediatrics (AAP) publication, Guidelines for Health Supervision, provides cursory oral health advice limited to fluoride supplementation and dental referral. The scientific literature aimed at pediatricians is also limited. A recent Medline search of the 3 commonly read pediatric journals identified 3. Pediatricians must be ensured that all of their patients, Medicaid and uninsured included, can receive timely preventive and restorative dental care. Pediatricians can expand their involvement in oral health prevention, but they can never replace the care that dental professionals provide. Further dialogue with our dental colleagues and joint advocacy efforts by the AAP and American Academy of Pediatric Dentistry are needed to address the serious problem of disparities in access to dental care. 4. Pediatricians will require sufficient resources to successfully assume greater involvement in oral health-related activities. Time pressures and inadequate staffing will make it difficult for pediatricians to devote the attention to oral health that all children deserve. pediatrician, oral health, anticipatory guidance, access to care, dental care.

Variation in GP referral rates: what can we learn from the literature?

Abstract: Background Variations in referral rates exist, at GP and practice level Although the National Institute for Clinical Excellence is to produce referral guidelines, it is unclear if this variation requires regulation A critical review of the literature on variation in referral rates was undertaken to see if existing evidence could inform the debate Objectives The aim of this study was to describe the variation in referral rates; to identify likely explanatory variables; and to describe the effect of GPs' decision making on the referral process Methods Six bibliographic databases, the Cochrane Library, the NHS Centre for Reviews and Dissemination, and the National Research Register were searched Results Patient characteristics explain <40% of the observed variation; practice and GP characteristics <10% The availability of specialist care does affect referral rates, but its influence on the observed variation of referral rates is not known Intrinsic psychological variables are important GPs who are less tolerant of uncertainty or who perceive serious disease to be a more frequent event may refer more patients There is a lack of consensus about what constitutes an appropriate referral, and the use of guidelines has had only limited success in altering referral behaviour Conclusions Variation in referral rates remains largely unexplained Targeting high or low referrers through clinical guidelines may not be the issue Rather, activity should concentrate on increasing the number of appropriate referrals, regardless of the referral rate Pressure on GPs to review their referral behaviour through the use of guidelines may reduce their willingness to tolerate uncertainty and manage problems in primary care, resulting in an increase in referrals to secondary care The use of referral rates to stimulate dialogue and joint working between primary and secondary care may be more appropriate

Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care

Abstract: OBJECTIVES: The aim of this study was to determine both the clinical and cost-effectiveness of usual general practitioner (GP) care compared with two types of brief psychological therapy (non-directive counselling and cognitive-behaviour therapy) in the management of depression as well as mixed anxiety and depression in the primary care setting. DESIGN: The design was principally a pragmatic randomised controlled trial, but was accompanied by two additional allocation methods allowing patient preference: the option of a specific choice of treatment (preference allocation) and the option to be randomised between the psychological therapies only. Of the 464 patients allocated to the three treatments, 197 were randomised between the three treatments, 137 chose a specific treatment, and 130 were randomised between the psychological therapies only. The patients underwent follow-up assessments at 4 and 12 months. SETTING: The study was conducted in 24 general practices in Greater Manchester and London. SUBJECTS: A total of 464 eligible patients, aged 18 years and over, were referred by 73 GPs and allocated to one of the psychological therapies or usual GP care for depressive symptoms. INTERVENTIONS: The interventions consisted of brief psychological therapy (12 sessions maximum) or usual GP care. Non-directive counselling was provided by counsellors who were qualified for accreditation by the British Association for Counselling. Cognitive-behaviour therapy was provided by clinical psychologists who were qualified for accreditation by the British Association for Behavioural and Cognitive Psychotherapies. Usual GP care included discussions with patients and the prescription of medication, but GPs were asked to refrain from referring patients for psychological intervention for at least 4 months. Most therapy sessions took place on a weekly basis in the general practices. By the 12-month follow-up, GP care in some cases did include referral to mental healthcare specialists. MAIN OUTCOME MEASURES: The clinical outcomes included depressive symptoms, general psychiatric symptoms, social function and patient satisfaction. The economic outcomes included direct and indirect costs and quality of life. Assessments were carried out at baseline during face-to-face interviews as well as at 4 and 12 months in person or by post. RESULTS: At 4 months, both psychological therapies had reduced depressive symptoms to a significantly greater extent than usual GP care. Patients in the psychological therapy groups exhibited mean scores on the Beck Depression Inventory that were 4-5 points lower than the mean score of patients in the usual GP care group, a difference that was also clinically significant. These differences did not generalize to other measures of outcome. There was no significant difference in outcome between the two psychological therapies when they were compared directly using all 260 patients randomised to a psychological therapy by either randomised allocation method. At 12 months, the patients in all three groups had improved to the same extent. The lack of a significant difference between the treatment groups at this point resulted from greater improvement of the patients in the GP care group between the 4- and 12-month follow-ups. At 4 months, patients in both psychological therapy groups were more satisfied with their treatment than those in the usual GP care group. However, by 12 months, patients who had received non-directive counselling were more satisfied than those in either of the other two groups. There were few differences in the baseline characteristics of patients who were randomised or expressed a treatment preference, and no differences in outcome between these patients. Similar outcomes were found for patients who chose either psychological therapy. Again, there were no significant differences between the two groups at 4 or 12 months. Patients who chose counselling were more satisfied with treatment than those who chose c

Female Sexual Dysfunction: Evaluation and Treatment

Abstract: Sexual dysfunction includes desire, arousal, orgasmic and sex pain disorders (dyspareunia and vaginismus). Primary care physicians must assume a proactive role in the diagnosis and treatment of these disorders. Long-term medical diseases, minor ailments, medications and psychosocial difficulties, including prior physical or sexual abuse, are etiologic factors. Gynecologic maladies and cancers (including breast cancer) are also frequent sources of sexual dysfunction. Patient education and reassurance, with early diagnosis and intervention, are essential for effective treatment. Patient history and physical examination techniques, normal sexual responses and the factors that influence these responses, and the application of medical and gynecologic treatments to sexual issues are discussed. Basic treatment strategies, which may be successfully provided by primary care physicians for most sexual dysfunctions, are outlined. Referral can be reserved for patients who do not respond to therapy.

Predictors of Dropout Among Men Who Batter: A Review of Studies With Implications for Research and Practice

Abstract: Identifying the characteristics of men who drop out of batterers' programs is crucial for prevention, intervention, and research. This article reviews studies of program attrition to establish a description of men who fail to complete group-based batterers' interventions. Studies indicate that men who drop out are more likely to be unemployed, be unmarried and/or childless, have lower incomes, and less education than men who remain. Dropouts are also more likely to have a criminal history, to report substance abuse or related problems, and to present with particular relationship concerns or orientations. The relationship between court referral and dropout was inconsistent across studies and may vary according to socioeconomic status. Psychopathology is consistently related to dropout, but may be associated with other factors (e.g., comorbidity or referral source). Age, race, childhood exposure to violence, and battering history are all inconsistently associated with dropping out. The implications of these findings for research and program development are discussed. Language: en

Self-reported physician practices for children with asthma: are national guidelines followed?

Abstract: Objective. To determine self-reported adherence to national asthma guidelines for children by primary care physicians in managed care; and, to analyze sources of variation in these practices by physician specialty and managed care practice type. Design. A survey of 671 primary care physicians (pediatricians and family physicians) practicing in 3 geographically diverse managed care organizations (MCO). Domains of interest included asthma diagnosis, pharmacotherapy, patient education and follow-up, and indications for specialty referral. Item formats included self-reports of usual practice and responses to case vignettes. Results. A total of 429 (64%) physicians returned surveys, 22 of whom did not meet criteria for inclusion in the analysis. Most respondents had both heard of (91%) and read (72%) the National Asthma Education and Prevention Program (NAEPP) guidelines. For diagnosis, 75% reported routine use of office peak flow measurement, but only 21% used spirometry routinely. Family physicians were more likely than pediatricians to use spirometry in diagnosis (odds ratio [OR] = 5.9), and less likely to recommend daily peak flow measurement (OR = .3). The median reported frequency of providing written care plans was only 50%. Though inhaled corticosteroids were deemed very safe or safe by 93%, almost half had specific concerns regarding at least 1 side effect, most commonly growth delay. Primary care physicians9 criteria for referral to an asthma specialist differed from those of the NAEPP panel in choosing to manage more severe patients without asthma specialist input. Family physicians were more likely than pediatricians to refer a child after a single hospitalization, 2 to 3 emergency department visits, after 2 exacerbations, or if the child was Conclusion. Most physicians for children report having read and adopted NAEPP guideline recommendations for asthma treatment, including generally appropriate use of medications. Opportunities for improvement exist in specific areas such as the use of written care plans, optimizing antiinflammatory dosing, and providing routine follow-up. Although physicians show evidence of awareness of national guidelines and knowledge consistent with much of their content, additional work is required to promote the use of self-management tools in practice.

Implementing shared decision-making in routine practice: barriers and opportunities.

Abstract: Objective Determine feasibility of shared decision-making programmes in fee-for-service hospital systems including physicians’ offices and in-patient facilities. Design Survey and participant observation. Data obtained during Phase 1 of a patient outcome study. Settings and participants Three hospitals in Michigan: one 299-bed rural regional hospital, one 650-bed urban community hospital, one 459-bed urban and suburban teaching hospital. All nurses and physicians who agreed to use the programmes participated in the evaluation (n = 34). Intervention Two shared decision-making® (SDP) multimedia programmes: surgical treatment choice for breast cancer and ischaemic heart disease treatment choice. Main outcome measures (1) clinicians’ evaluations of programme quality; (2) challenges in hospital settings; and (3) patient referral rates. Results SDP programmes were judged to be clear, accurate and about the right length and amount of information. Programmes were judged to be informative and appropriate for patients to see before making a decision. Clinicians were neutral about patients’ desire to participate in treatment decision-making. Referral volume to SDPs was lower than expected: 24 patients in 7 months across three hospitals. Implementation challenges centred on time pressures in patient care. Conclusions Productivity and time pressure in US health care severely constrain shared decision-making programme implementation. Physician referral may not be a reliable mechanism for patient access. Possible innovations include: (1) incorporation into the informed consent process; (2) provider or payer negotiated requirement in the routine hospital procedure to use the SDP as a quality indicator; and (3) payer reimbursement to professional providers who make SDP programmes available to patients.

The Stigma of Psychological Problems in a Work Environment: Evidence From the Screening of Service Members Returning From Bosnia1

Abstract: The present research examined the stigma associated with psychological problems among service members returning from the United States peacekeeping mission to Bosnia. The results show that admitting a psychological problem in the military is perceived as muchmore stigmatizing than admitting a medical problem. Service members had more concerns about stigmatization and felt more uncomfortable discussing psychological problems than medical problems, and these feelings were magnified when service members were being screened with their units rather than alone. Service members also reported a lesser likelihood of following through with a psychological referral than with a medical referral. However, participants who discussed psychological issues with a therapist felt the screening was more beneficial than those who did not discuss their responses. The results address the neglected topic of the stigma associated with psychological problems in the workplace.

Effect of language barriers on follow-up appointments after an emergency department visit.

Abstract: Research has shown that Latinos average fewer physician visits per year than other ethnic groups.1,2 Many factors may contribute to Latinos' lower use of physician services, including lower rates of health insurance coverage,3 lower levels of income and education,3,4 and limited English proficiency.5–7 One study found that Latinos with limited English proficiency reported fewer visits than native English-speaking patients,8 while an analysis of the 1987 National Medical Expenditure Survey found that insurance was the predominant determinant of the number of physician visits and inability to speak English was not a significant predictor of physician visits.9 Patients with limited English proficiency may also utilize health care less because of dissatisfaction with the health care they have received in the past. Baker et al. found that Latino patients who communicated through an interpreter or who did not have an interpreter when they thought one was necessary were less satisfied with the patient-provider relationship.10 Similarly, Carrasquillo et al. reported that emergency department patients who said that English was not their first language were less satisfied overall and reported more communication problems.11 There may also be differences in how physicians care for Latino patients, and this may affect their satisfaction and future health care use. Todd et al. reported that Hispanics with isolated long-bone fractures were twice as likely as non-Hispanic whites to receive no pain medication in an emergency department.12 Latinos with limited English proficiency may also be less likely to receive follow-up appointments after an initial physician visit because of discrimination, communication barriers leading to misdiagnosis or lack of awareness of a problem, or even physician frustration over difficulty communicating. To our knowledge, no study has investigated the effects of limited English proficiency or communicating through an interpreter on physician referral patterns. Finally, Latinos with limited English proficiency might be less likely to comply with referral appointments because of dissatisfaction, or poor understanding of the reason for the referral, or simply because they are unaware that they are supposed to have a follow-up appointment. Manson found that asthmatic patients receiving extended follow-up care in an ambulatory care setting from a language-discordant physician were more likely to miss office appointments than were patients with a language-concordant physician.13 To further examine these issues, we conducted this study to determine the association between language barriers and (1) rates of referral for a follow-up appointment after an emergency department visit, (2) patients' knowledge that an appointment had been scheduled, and (3) actual compliance with scheduled follow-up appointments.

Coordination of specialty referrals and physician satisfaction with referral care.

Abstract: communicated with the specialist compared with those for which neither activity occurred. Referring physicians’ satisfaction ratings were significantly increased by any type of specialist feedback and were highest for referrals involving specialist feedback by both telephone and letter. Elements of specialists’ letters that significantly increased physician ratings of letter quality included presence of patient history, suggestions for future care, follow-up arrangements, and plans for comanaging care; only the inclusion of plans for comanaging patient care was significantly related to the referring physicians’ overall satisfaction. Conclusions: Better coordination between referring physicians and specialists increases physician satisfaction with specialty care and enhances referral completion. Improvements in the referral process may be achieved through better communication and collaboration between primary care physicians and specialists. Arch Pediatr Adolesc Med. 2000;154:499-506

Trends in the indications for penetrating keratoplasty in the midwestern United States.

Abstract: Purpose.To examine the leading indications and identify the changing trends for penetrating keratoplasty (PKP) in the midwestern United States.Methods.The indications for PKPs at a single center tertiary care referral practice were tabulated to assess trends from 1982 to 1996. The data analysis was

Frequent users of the emergency department: a program to improve care and reduce visits

Abstract: The authors describe a case-management program for frequent users of the emergency department. The study had a single-subject design, with evaluation for each patient of the number of visits to the emergency department for a 12-month period before referral to the program and a similar period after implementation of an individualized care plan. Referrals were made on the basis of 2 or more of the following criteria: chronic medical condition, complex medical condition, drug-seeking behaviour, violent behaviour and abusive behaviour. A multidisciplinary team developed the individualized care plans. Twenty-four patients agreed to participate. For the 12-month period before their referral, these patients accounted for a total of 616 (median 26.5) visits to the emergency department; for a similar period after implementation of the care plans, they accounted for 175 (median 6.5) visits. The difficult-case management program appeared to be effective in reducing the total number of visits to the emergency department during the study period and in improving the care for these patients.

Consequences of late referral on patient outcomes

Abstract: There is growing awareness of a need not only to identify patients with chronic renal failure (CRF) at an earlier stage in the disease process, but also to initiate treatment strategies earlier, in order to delay both progression of CRF and co-morbid diseases and to define the optimal time required to prepare CRF patients for renal replacement therapy (RRT). These three strategies are linked, and rely on appropriate identification of patients at risk of renal disease. The challenge currently facing nephrologists is both how to minimize the consequences of late referral and how to improve the timeliness of referral. Published studies support the notion that outcomes are poor in patients who access specialized nephrology care late in the course of their renal disease (just prior to the need for dialysis). A National Institute of Health consensus publication recommends early referral to a multidisciplinary renal care team, and the recent Canadian Society of Nephrology guidelines recommend that at least 12 months are needed prior to initiation of dialysis for adequate medical and psychological preparation for RRT. Despite these recommendations, a substantial proportion (20-50%) of patients starts dialysis without prior exposure to nephrologists. Limited data exist on current referral patterns to nephrologists. Diabetes and/or hypertension cause renal disease in up to 40% of patients requiring dialysis. These patients are presumably being monitored by internists, endocrinologists or cardiologists, and many referrals come from these physicians; other patients may be referred by general practitioners. Data regarding disease status at the time of referral are also limited. Substantial cardiovascular disease and risk factors are evident at the time of referral. Most of the literature describes data for those starting dialysis (i.e. late referral) rather than a broader spectrum of all patients with renal insufficiency referred to nephrologists. Reasons for late referral include insensitivity of current screening tools. Serum creatinine is well known to be an inaccurate marker of renal dysfunction, and too insensitive to identify patients with very early stages of disease, thus contributing to the prevalence of late referrals. Physician and patient attitudes are other barriers to early referral and need to be studied more fully. The consequences of late referrals include increased morbidity, mortality, and resource utilization. There is also an impact on patients' quality of life and missed opportunities for pre-emptive transplantation. Late referral also limits therapeutic options, and these limitations have consequences on long-term outcomes once patients are on dialysis. It is clear that late referral of patients with CRF obviates the opportunity for significant delay of disease progression and institution of proactive strategies to reduce the overall burden of illness in the population. There is ample evidence that strategies to delay progression of renal disease are effective, as are strategies to reduce cardiovascular disease. Anaemia and a fall in haemoglobin concentration have been associated with left ventricular hypertrophy and with growth of the left ventricle. A combined approach is necessary for best nephrological clinical practice, with a clear definition of early renal insufficiency; this will involve the development of tools to permit early identification of patients with early renal insufficiency, and the implementation of strategies to optimize treatments aimed at both delaying progression and preparing patients for RRT.

Why Do Physicians Vary So Widely in Their Referral Rates

Abstract: OBJECTIVE: To determine which physician practice and psychological factors contribute to observed variation in primary care physicians’ referral rates.

The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties

Abstract: Ramsay J, Campbell JL, Schroter S, Green J and Roland M. The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties. Family Practice 2000; 17: 372‐379. Objectives. The aim of this study was to describe the psychometric properties of the General Practice Assessment Survey (GPAS) and its acceptability to patients in the UK. GPAS comprises seven multiple item scales and two single item scales addressing nine key areas of primary care activity (access, technical care, communication, inter-personal care, trust, knowledge of patient, nursing care, receptionists and continuity of care). A further four single items relate to patients’ perceptions of the GP’s role in referral and co-ordination of care, their willingness to recommend their GP and their overall satisfaction with care received. Methods. Two hundred consecutive patients attending routine consulting sessions at 55 inner London practices were invited to complete the GPAS questionnaire. The acceptability, reliability and validity of GPAS was assessed using standard psychometric techniques. Results. Out of 11 000 patients, 7247 (66%) completed a questionnaire in a GP surgery. Fifty-five out of a separate sample of 77 patients attending one practice completed a second questionnaire mailed to them 1 week following their attendance. GPAS was acceptable to patients as evidenced by low proportions of missing data for all items, and a full range of possible scores for all but one of the nine scales. Reliability of the instrument was good. Multiple item scales had excellent internal consistency, high item‐total correlations, and test‐retest reliability. Scaling assumptions were confirmed, with six of the seven scales achieving 100% scaling success (convergent and discriminant validity). Construct validity was evident, although this requires further evaluation against external measures. Conclusions. GPAS is a useful instrument for assessing several important dimensions of primary care. It is acceptable, reliable and valid, and has the potential for versatility in mode of administration. It will be a useful instrument for practices, primary care groups and primary care researchers evaluating key areas of primary care activity. Further work is required to evaluate its performance in non-inner-city settings and to evaluate further its validity against external criteria.

Transforming Insurance Coverage Into Quality Health Care: Voltage Drops From Potential to Delivered Quality

Abstract: Although the US health care system is often touted as one of the best in the world, disparities exist in quality of care received by different populations, in different regions, and across different institutions and clinicians. Initiatives to provide access to health insurance have been a major policy tool to ensure that Americans receive high-quality health care. However, availability of insurance coverage does not automatically lead to high-quality care. This article explores points of vulnerability in the US health care system at which the potential to achieve high-quality care can be lost: (1) access to insurance coverage; (2) enrollment in available insurance plans; (3) access to covered services, clinicians, and health care institutions; (4) choice of plans, clinicians, and health care institutions; (5) access to a consistent source of primary care; (6) access to referral services; and (7) delivery of high-quality health care services. Ensuring high-quality health care requires that each of these "voltage drops" be recognized and addressed. JAMA. 2000;284:2100-2107.

Manual handling activities and injuries among nurses: an Australian hospital study.

Abstract: The aims of this study were to identify patterns of manual handling activities and their associated injuries and consequences among nurses working at a large teaching and referral medical centre in Melbourne, Australia. A self-report 140-item questionnaire was distributed to 523 registered nurses working full time at the medical centre. Of the 269 (51.4%) nurses who completed the questionnaire, 108 (40.1%) retrospectively reported an injury associated with manual handling activity, of which 75.9% (82) comprised back injuries. When all full-time nurses working at the medical centre are considered, the prevalence of all manual handling injuries was 20.6% (n=108) and 15.7% (n=87) for back injuries. About two-thirds (67.6%) of all manual handling injuries were associated with direct patient care activities and another third (32.4%) with non-direct patient care activities. Approximately one-third (34.3%) of all injuries were associated with lifting patients and this activity comprised one half of all causes associated with injuries arising from direct patient care activities. The consequences of injuries were significant. Recommendations for reducing manual handling activities and injuries are made and future research directions are discussed.

Individualized stepped care of chronic illness.

Abstract: The routine care of people with chronic illnesses often fails to follow evidence-based guidelines or to achieve optimal outcomes.1,2 Because of the high prevalence and costs of chronic illness care3,4 and the key role of primary care physicians in managing chronic illness, enhancing care and outcomes in primary care settings is a public health imperative. There are important general issues about how chronic conditions are effectively managed.1,5,6 Identifying these generalities is essential if the potential advantages of primary care of chronic illness are to be realized. Evidence-based guidelines for diverse chronic conditions identify similar elements of patient care (first table,second table).7,8,9,10,11,12 These elements include a well-defined care plan, patient education, scheduled follow ups, outcome and adherence monitoring, the targeted use of specialist consultation or referral, and the use of stepwise treatment protocols. Despite evidence that these elements of chronic illness care improve patient outcomes, they are often inadequately organized and delivered.1 Table 1 Generic elements of chronic illness care included in evidence-based guidelines for 5 chronic conditions Table 2 Individualized stepped care: a scheme for managing chronic illness in primary care

Barriers to outpatient cardiac rehabilitation participation and adherence.

Abstract: BACKGROUND A significant proportion of eligible patients do not participate in outpatient cardiac rehabilitation. The purpose of this study was to identify barriers to participation and adherence to outpatient cardiac rehabilitation by querying program staff. METHODS In January 1999, a survey was mailed to all North Carolina program directors of outpatient cardiac rehabilitation programs. The response rate was 85% (61/72). RESULTS Across programs, the most common barrier to participation in outpatient cardiac rehabilitation was financial. Other barriers identified by program directors included lack of patient motivation, patient work or time conflicts, and lack of physician support or referral. When program directors were asked to cite reasons that referred patients provided for not participating in rehabilitation, the most common answer was financial or lack of motivation or commitment. The most common reason cited for dropping out of the rehabilitation program was work, followed by financial reasons and lack of motivation or commitment. CONCLUSIONS The results of this statewide survey of program directors indicated a common set of barriers that many patients currently face to begin and continue participating in outpatient cardiac rehabilitation.