Showing papers on "Referral published in 2002"

Early referral recommendation for newly diagnosed rheumatoid arthritis: evidence based development of a clinical guide

Abstract: Objective: To develop a referral recommendation that may serve as a clinical guide for primary care doctors, enabling them to identify patients with suspected RA during the early inflammatory stages. Methods: Key points of the referral criteria were formed based on a thorough literature review target- ing early RA, early arthritis clinics, DMARD treatment for early RA, prognostic factors of disease pro- gression, early RA clinical trials, and quality of life. Evidence was graded using the methods defined by Shekelle et al. A draft version of the criterion was circulated among the authors for critical evalua- tion. A consensus integrated these comments. Results: Clinical evidence strongly supports the observations that structural damage occurs early in active RA and that early DMARD treatment improves the long term outcome of the disease. The obser- vations indicate that rapid referral to a rheumatologist is advised when RA is suspected. This may be supported by the presence of any of the following: >3 swollen joints, metatarsophalangeal/ metacarpophalangeal involvement, and morning stiffness of >30 minutes. Conclusion: The proposed early referral recommendation is a viable tool for primary care doctors to identify potential patients with active RA early in the disease. Early referral to a rheumatologist for definitive diagnosis and early DMARD treatment should improve the long term outcome of RA.

Emergency medical care in developing countries: is it worthwhile?

Abstract: Prevention is a core value of any health system. Nonetheless, many health problems will continue to occur despite preventive services. A significant burden of diseases in developing countries is caused by time-sensitive illnesses and injuries, such as severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and unintentional injuries, postpartum bleeding, and acute myocardial infarction. The provision of timely treatment during life-threatening emergencies is not a priority for many health systems in developing countries. This paper reviews evidence indicating the need to develop and/or strengthen emergency medical care systems in these countries. An argument is made for the role of emergency medical care in improving the health of populations and meeting expectations for access to emergency care. We consider emergency medical care in the community, during transportation, and at first-contact and regional referral facilities. Obstacles to developing effective emergency medical care include a lack of structural models, inappropriate training foci, concerns about cost, and sustainability in the face of a high demand for services. A basic but effective level of emergency medical care responds to perceived and actual community needs and improves the health of populations.

Secondary prevention of coronary heart disease in the elderly (with emphasis on patients > or =75 years of age): an American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention.

Abstract: The overall aging of the American population and improving survival of patients with coronary heart disease (CHD) has created a large population of older adults (≥65 years of age) eligible for secondary prevention The prevalence of chronic ischemic heart disease in men and women ≥65 years of age in the United States in 1995 was 83 per 1000 men and 90 per 1000 women Among those ≥75 years of age, the prevalences were 217 per 1000 for men and 129 per 1000 for women1 Increasing evidence has accumulated over the past 2 decades that elderly individuals with CHD can benefit greatly from exercise training and other aspects of secondary prevention2 Traditionally, components of secondary prevention programming (including exercise; smoking cessation; management of dyslipidemia, hypertension, diabetes, and weight; and interventions directed at depression, social isolation, return to work, and other psychosocial issues) have been provided by the clinician in the office setting or through cardiac rehabilitation programs Cardiac rehabilitation programs are particularly well suited to the provision of secondary prevention services, but unfortunately, many older patients who would derive benefit from these interventions do not participate because of lack of referral or a variety of societal and other barriers3 It is the purpose of this Scientific Statement to provide an update on the benefits of specific secondary prevention risk factor interventions in this age group and, where possible, to delineate benefits in the older elderly (≥75 years of age) An increased awareness on the part of physicians, nurses, third-party payers, and patients and their families of the benefits of secondary prevention programs to older adults will provide a basis for referral and aid in the implementation of such programming The clinical manifestations of CHD in older patients represent the effects of the disease superimposed on the physiological effects …

When the treatment goal is not cure: are cancer patients equipped to make informed decisions?

Abstract: PURPOSE: Informed decision making now is considered the underpinning of ethical medical practice. We aimed to determine the extent to which patients with incurable cancer are adequately informed of their prognosis and treatment options and encouraged to participate in treatment decisions. PATIENTS AND METHODS: One hundred eighteen cancer patients with incurable disease presenting for an initial consultation with one of nine oncologists at two Sydney tertiary referral hospitals participated in the study. Consultations were recorded on audiotape to permit a content analysis of doctor-patient interactions. We devised a coding system to assess disclosure of information and to evaluate doctor encouragement of patient participation in treatment decision making. Patient recall, satisfaction, anxiety, and perceptions of the decision-making process were assessed to determine the effects of informed decision making on patient outcomes. RESULTS: Most patients were informed about the aim of anticancer treatment (84.7...

Patient trust in the physician: relationship to patient requests

Abstract: BACKGROUND Patient trust is a key component of the patient-physician relationship. A previous qualitative study has suggested that a low level of trust is associated with unfulfilled requests. OBJECTIVE Our aim was to test the hypothesis that patients with a low level of trust will be more likely to report that requested or needed services were not provided during an office visit. METHODS An observational study was carried out of office visits by 732 patients of 45 physicians (16 family physicians, 18 general internists and 11 cardiologists), within two managed care settings. Participants were consecutive, English-speaking patients, age 18 and older who had a significant health concern. Visit questionnaires were completed by 68% of patients known to be eligible. Post-visit measures included services requested (information, examination, prescription, test or referral); services provided; and requested or needed services not provided during the visit. Measures at 2-week follow-up included patient satisfaction, intended adherence to advice, interval contacts with the health system and symptom improvement. RESULTS After adjustment for patient and physician characteristics, patient trust in the physician was not associated with the likelihood that a service was requested or provided during the visit, with the exception that prescription of a new medication was more frequent among patients with higher trust. In contrast, patients with low trust prior to the visit consistently were more likely to report that a needed or requested service was not provided (P < 0.001 for all services). Patients with a low level of trust were less satisfied with their care (P < 0.001), were less likely to intend to follow the doctor's advice (P < 0.001) and were less likely to report symptom improvement at 2 weeks (P = 0.03). CONCLUSIONS Patients with a lower level of trust in their physician are more likely to report that requested or needed services are not provided. Understanding this relationship may lead to better ways of responding to patient requests that preserve or enhance patient trust, leading to better outcomes.

Contemporary practices in school psychology: A national survey of roles and referral problems

Abstract: Eight hundred school psychologists who were members of the National Association of School Psychologists were mailed a survey designed to assess their roles, types of referrals, consultation practices, and crisis team involvement. Three hundred seventy (49%) completed surveys were analyzed. Assessment was the most common role followed distantly by consultation. Academic problems were the most frequent type of referral with reading being the most common concern. Of the behavioral referrals, externalizing problems were more frequent than internalizing concerns. Behavioral consultation was the most common model used but less than half of respondents follow all of the stages. Only forty percent use an evaluative component in consultation. A majority of the informants had some involvement with their schools' crisis team. Implications of these findings for training, professional development, and future roles are discussed. © 2002 Wiley Periodicals, Inc.

Nurses' attitudes towards clients who self-harm

Abstract: Background. Deliberate self-harm is frequently encountered by emergency department (ED) nurses. However, clients are often dissatisfied with the care provided and clinicians feel ambivalent, helpless or frustrated when working with clients who self-harm. Aim. The aim of the study was to develop and test a scale to identify relevant dimensions of ED nurses' attitudes to clients who present with self-injury. Methods. Items on Attitudes Towards Deliberate Self-Harm Questionnaire (ADSHQ) were drawn from a literature review and focus group discussions with ED nurses. The tool was piloted with 20 ED nurses not working in the target agencies. A survey of nurses working within 23 major public and 14 major private EDs in Queensland, Australia ( n = 1008) was then undertaken. Results. A total of 352 questionnaires were returned (35% response). Analysis revealed four factors that reflected nurses' attitudes toward these clients. The factors related to nurses' perceived confidence in their assessment and referral skills; ability to deal effectively with clients, empathic approach; and ability to cope effectively with legal and hospital regulations that guide practice. There was a generally negative attitude towards clients who self-harm. Correlations were found between years of ED experience and total score on the ADSHQ, and years of ED experience and an empathic approach towards clients who deliberately self-harm. Conclusion. There is a need for continuing professional development activities to address negative attitudes and provide practical strategies to inform practice and clinical protocols.

Impact of a program to improve adherence to diabetes guidelines by primary care physicians

Abstract: OBJECTIVES —Previous studies have shown that primary care physician (PCP) adherence to diabetes guidelines is suboptimal. We sought to determine the state of diabetes care given by independently practicing PCPs in a rural county in Indiana and whether a multifaceted intervention targeting PCPs, patients, and the health care system would improve adherence to diabetes guidelines. RESEARCH DESIGN AND METHODS —Baseline audits to assess adherence to diabetes guidelines were done on charts of the seven PCPs in the county. Audits were repeated after development of local consensus guidelines and feedback of baseline performance and after implementation of various interventions (practice aids, physician detailing, patient education sessions, and implementation of computerized individual meal planning). RESULTS —Before any intervention, rates of adherence to guidelines were low (15% for foot exams, 20% for HbA1c measurement, 23% for eye exam referrals, 33% for urine protein screening, 44% for lipid profiles, 73% for home glucose monitoring, and 78% for blood pressure measurements). One year after development of local consensus guidelines and feedback of baseline performance, significant improvements were seen in blood pressure measurements (71 vs. 83%; P = 0.002), foot exams (19 vs. 42%; P < 0.001), HbA1c measurements (26 vs. 37%; P = 0.012), and PCP eye exams (38 vs. 46%; P = 0.043); a trend toward improvement was seen in referral to eye specialists (25 vs. 33%; P = 0.059). After a second year of multiple interventions, only blood pressure measurements (70 vs. 92%; P < 0.001) and foot exams (22 vs. 47%; P < 0.001) remained significantly improved; all other areas returned to rates indistinguishable from baseline. CONCLUSIONS —In busy primary care practices lacking organizational support and computerized tracking systems, sustained improvements in diabetes care are difficult to attain using traditional physician-targeted approaches.

Primary Care Referral of Children With Psychosocial Problems

Abstract: Objectives To examine primary care provider referral patterns for patients with psychosocial problems and to understand the factors that influence whether a mental health referral is made. Design Secondary analysis of the Child Behavior Study data collected during 1994-1997 from background survey of providers, visit survey of providers and parents, and follow-up survey of parents. Setting Two hundred six primary care offices in the United States, Canada, and Puerto Rico. Patients Four thousand twelve of 21 150 patients aged 4 to 15 years in the Child Behavior Study with a clinician-identified psychosocial problem. Main Outcome Measures Referral for psychosocial problem at index visit and reported follow-up with mental health care provider within 6 months. Results Six hundred fifty (16%) of 4012 patients with psychosocial problems were referred at the initial visit. In multivariate analysis, significant factors associated with likelihood of referral included patient factors (severity, type of problem, academic difficulties, prior mental health service use) and family factors (mental health referral of parent); however, none of the provider factors were significant. Clinicians reported frequent barriers to referral and mental health services in the general background survey; however, these factors were rarely reported as influences on individual management decisions. Only 61% of referred families reported that their child saw a mental health care provider in the 6-month period after the initial primary care referral. Conclusions Most psychosocial problems are initially managed in primary care without referral. However, referral is an important component of care for patients with severe problems, and many families are not effectively engaged in mental health services, even after a referral is made.

Oral health during pregnancy.

Abstract: The purpose of this article is to explore how poor oral health affects pregnancy and to review current recommendations for dental care during pregnancy. While nurses are concerned with numerous aspects of the health of pregnant women, the health of maternal and fetal dentition may be overlooked. However, due to recent findings that periodontal disease may be a risk factor for preterm low birthweight, nurses and other maternal healthcare providers are becoming more aware of oral health during pregnancy. It is important to understand that establishing a healthy oral environment is the most important objective in planning the dental care for the pregnant patient. This objective is achieved by adequate plaque control (brushing and flossing) and professional prophylaxis including coronal scaling, root planing, and polishing. Nurses, nurse practitioners, and nurse-midwives should include assessment of maternal dentition and referral for dental problems as part of their prenatal practice. Patients should be encouraged to schedule elective dental treatment during the second trimester but seek prompt care for acute dental problems. Teaching related to oral health during pregnancy should include the importance of proper nutrition to ensure maternal and fetal oral health, including taking prenatal vitamins and eating foods high in protein, calcium, phosphorus, and vitamins A, C, and D. Potential teratogens that may be encountered during dental care should also be discussed. Nurses can be vital in improving perinatal outcomes and maternal/fetal dental health through screening, referral, and education of their pregnant clients.

Accuracy of Pediatric Primary Care Providers’ Screening and Referral for Early Childhood Caries

Abstract: Purpose. Tooth decay is one of the more common diseases of childhood. Slightly >40% of US children are already affected by the time they reach kindergarten. Primary care physicians can play an important role in prevention and control of this disease because of their ready access to this population. Unlike dentists, they see a large percentage of children during their infant and toddler years. However, few studies have been conducted on oral screenings and referrals by primary care physicians or the effectiveness of their oral health preventive activities. The purpose of this study was to determine the accuracy of pediatric primary care providers’ screening and referral for Early Childhood Caries. Methods. We sought to compare independent, blinded oral screening results and referral recommendations made by primary care providers with those of a pediatric dentist, considered for purposes of the study to be the reference gold standard. The study was conducted at a private pediatric group practice in North Carolina. The practice was selected because it serves a large volume of Medicaid patients and includes a large number of pediatric primary care providers (11 pediatricians and 1 nurse practitioner). Study participants included Medicaid-eligible children younger than 36 months of age with erupted teeth. The pediatric primary care providers in this practice received 2 hours of training in infant oral health. The training consisted of a review of the study methods and clinical slides illustrating dental caries in various stages of progression. Specific instructions were given to the providers on how to recognize a cavitated carious lesion and how to determine when a dental referral is needed. Providers were instructed to refer any child with 1 or more cavitated carious lesions, soft tissue pathology, or evidence of trauma to the teeth or mouth. Before commencing the study, calibration and a comparative analysis were performed to establish reliability and validity of the examinations performed by the pediatric dentist. Both a pediatric dentist and a pediatric primary care provider conducted a dental screening on each child and recorded carious teeth and whether a dental referral was needed. Sensitivity and specificity were calculated to compare the pediatric primary care providers’ screenings to the gold standard (pediatric dentist) in 3 categories: caries at the tooth level, caries at the patient level (1 or more affected teeth), and need for referral. Results. The final study sample consisted of 258 preschool-aged children (122 males and 136 females) with a mean age of 21.2 months (standard deviation [SD]: 9.13). One hundred eighty-four (71.3%) of the participants were white, 58 (22.5%) were black, and 16 (6.2%) were Hispanic. Tooth-Level Analysis: The pediatric dentist reported an average of 0.30 (SD: 0.005) cavitated teeth per child, whereas the pediatric primary care providers reported a mean of 0.25 (SD: 0.004). This difference was not statistically significant (t test). The pediatric dentist identified 80 (2.4%) teeth with cavitated carious lesions, whereas the pediatric primary care providers identified 64 (1.9%), 25 of which were false-positives. Their screening results include 41 false-negative teeth. Thus, the primary care providers tended to under-count the number of teeth with carious lesions. They achieved a sensitivity of 0.49 (95% confidence interval [CI]: 0.47–0.51) and a specificity of 0.99 (95% CI: 0.99–1.0) when their screening results for individual teeth were compared with the gold standard. Patient-Level Analysis: At the patient level, the pediatric dentist identified 25 (9.7%) children with 1 or more teeth affected by cavitated lesions. The pediatric primary care providers collectively identified 30 (11.6%) children who had cavitated lesions. They achieved a sensitivity of 0.76 (95% CI: 0.71–0.81) and a specificity of 0.95 (95% CI: 0.93–0.98) in identifying those children with cavitated carious lesions. There were 6 false-negatives and 11 false-positives when the pediatric primary care providers’ findings were compared with the gold standard. At the patient-level, the positive predictive value of the dental screening was 0.63 and the negative predictive value was 0.97. Dental Referral: The pediatric dentist referred a total of 27 (10.5%) children to a dentist. Two of these children were referred for trauma and the other 25 were referred for cavities. The pediatric primary care providers referred a total of 23 (8.9%) children to a dentist. Two referrals were made because the provider was concerned about stains on the teeth, whereas the remaining 21 were referred for cavities. The pediatric primary care providers achieved a sensitivity of 0.63 (95% CI: 0.57–0.69) and a specificity of 0.98 (95% CI: 0.96–0.99) when their recommendations for referral were compared with the gold standard. The number of children receiving a referral from a pediatric primary care provider for cavities (N = 21) was less than the number of children they identified as having cavities (N = 30). The providers as a whole tended to under-refer, and only 70% of children with evidence of dental disease received a referral. Conclusions. After 2 hours of training in infant oral health, the pediatric primary care providers in this study achieved an adequate level of accuracy in identifying children with cavitated carious lesions. Additional training and research would be needed to optimize pediatric primary care providers’ identification of carious teeth if that were the goal of screening. However, the purpose of screening by nondental personnel generally is to accurately identify those in need of referral, which does not require a tooth-by-tooth identification of cavities. Additional research is also needed to determine how to improve dental referrals by pediatric primary care providers. Results of our study suggest that dental screenings can easily be incorporated into a busy pediatrics practice and that pediatric primary care providers can significantly contribute to the overall oral health of young children by the identification of those children who need to be seen by a dentist.

Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons.

Abstract: OBJECTIVE To understand better the barriers among orthopedic surgeons and primary care physicians in identifying and treating possible osteoporosis in patients hospitalized with a fragility fracture sustained spontaneously or from a fall no greater than standing height. Methods A 1-page, 7-question survey was sent to 35 admitting orthopedic surgeons and 75 primary care physicians at a midwestern managed care organization in March 2001. Returned surveys were collected until 30 days had passed since the mailing. Primary care physicians were board-certified family practitioners and internal medicine physicians. All orthopedists were admitting surgeons in the hospital system. Responders were anonymous, and posted surveys were returned to the Orthopaedic Collaborative Practice office. The surveys were color-coded to separate responses from orthopedic surgeons and primary care physicians. Results Thirty-one surveys were returned: 23 (31%) from primary care physicians and 8 (23%) from orthopedic surgeons. Survey respondents agreed that the responsibility for postfracture attention to nutritional needs, including calcium and vitamin D, rested with the primary care provider. When asked about barriers to recommending bone mineral density testing with dual energy x-ray absorptiometry, 9 primary care physicians (39%) thought this type of testing was unnecessary for treatment, and 4 primary care physicians (17%) thought a barrier was caused by patient frailty. Primary care physicians indicated that potential adverse effects of medication (n=14 [61%]) and cost of therapy (n=13 [57%]) were the main factors limiting treatment. When asked to identify the single most important barrier in treatment, 14 physicians (61%) indicated cost was the greatest deterrent. Twentyone primary care physicians (91%) reported they would be more likely to treat a patient with osteoporosis if a safe medication with proven fracture risk reduction were available. Primary care physicians indicated they were more likely to treat independently living adults (n=12 [52%]) and women compared with men (n=15 [65%]). All orthopedic surgeons (n=8) were willing for all patients to be evaluated in consultation with a nurse practitioner. Primary care respondents were less apt to agree with a nurse practitioner referral (n=5 [22%]). Both primary care physicians (n=16 [70%]) and orthopedic surgeons (n=4 [50%]) agreed that there is a need for increased primary care education about managing osteoporosis in patients hospitalized with low-impact fracture. Conclusions Orthopedic surgeons were consistent in their opinion that postfracture attention to osteoporosis should rest with the primary care physician. Primary care physicians agree but report that cost and possible adverse effects of medication are major barriers to this care. Despite therapies for high-risk postfracture patients showing relative safety and proven efficacy in reducing future fractures, deterrents to this care are focused on cost and potential adverse effects. Further education is needed to promote a standard of care for the postfracture patient that is directed toward the prevention of a subsequent fracture.

Migraine-associated dizziness: patient characteristics and management options.

Abstract: ObjectiveTo determine patient characteristics and effectiveness of therapy for migraine-associated dizziness.Study DesignRetrospective chart review.SettingTertiary referral center.PatientsPatients were identified through a code query of billing records for the diagnosis of migraine-associated vertig

Stress, Biases, or Professionalism: What Drives Teachers' Referral Judgments of Students with Challenging Behaviors?.

Abstract: This study sought to identify the relative contributions of some of the variables that are thought to influence teachers' referral judgments.The primary variables that have been identified in the l...

Transitional care of older adults.

Abstract: This chapter reviews 94 published research reports on transitional care of older adults by nurse researchers and researchers from other disciplines. Reports were identified through searches of MEDLINE, CINAHL, HealthSTAR, Sociological Abstracts and PsycINFO using combinations of the following search terms: transitional care, discharge planning, care coordination, case management, continuity of care, referrals, postdischarge follow-up, patient assessment, patient needs, interventions, and evaluation. Reports were included if published between 1985 and 2001, if conducted on samples age 55 and older, if relevant to nursing research, and if published in English. Intervention studies had to have a control or comparison group and a test for statistical significance. Four key findings from this review were identified. A high proportion of elders and their caregivers report substantial unmet transitional care needs, with the need for information and increased access to services consistently among the top priorities. Differences in expectations between and among patients, families, and health care providers, and the need for increased patient and family involvement in decision making, are common themes in discharge planning studies. Gaps in communication have been identified through the discharge planning process. Evidence about the effects of innovations in transitional care on quality and cost outcomes is sparse. Four main recommendations are made. Differences in older adults' transitional care needs based on race, ethnicity, and educational level, with attention to potential disparities, require further study. Studies of strategies to promote effective involvement of patients and families in decision making throughout discharge planning are needed. The development and testing of referral and other information systems designed to promote the transfer of accurate and complete information across sites of care should be a research focus. A priority for future research should be continued study of strategies to improve transitional care outcomes of older adults and their caregivers.

Health-related quality of life and mobility of patients awaiting elective total hip arthroplasty: a prospective study

Abstract: Background: Waits for elective total hip arthroplasty for osteoarthritis are common in publicly funded health care systems, but they may lead to poorer postoperative outcomes and loss of health-related quality of life (HRQOL) through progressive pain and immobility during the wait These issues have not been examined from the time of referral for surgery Our primary objective was to test whether a longer wait was associated with poorer postoperative HRQOL Methods: Patients needing possible total hip arthroplasty for osteoarthritis were identified upon referral to a surgeon in London, Ont Outcome measures, including the Western Ontario McMaster (WOMAC) Osteoarthritis Index and mobility in the 6-Minute Walk, were assessed at baseline and every 3–6 months thereafter until at least 3 months after the surgery Results: Of 553 potentially eligible patients referred for surgical assessment, 123 were placed on a waiting list for total hip arthroplasty; 114 underwent the procedure, and 99 of them returned for postoperative assessment No significant differences in HRQOL or mobility were seen postoperatively between patients with short waits and those with long waits (a priori definitions ≤ 6 months and > 6 months respectively) At referral, however, patients with short waits had poorer HRQOL and were less mobile than those with long waits ( p = 0002 for WOMAC Osteoarthritis Index total score, 0001 for pain, 0009 for stiffness and 0008 for function; p = 0006 for 6-Minute Walk results) Patients with short waits experienced larger gains in these measures from the time of referral until the postoperative assessment than did patients with long waits ( p = 0002 for WOMAC Osteoarthritis Index total score, p = 006 for 6-Minute Walk results) For patients with long waits, increases in the WOMAC Osteoarthritis Index total score exceeded 10% and losses in walking distance exceeded 30 m from the time of referral to surgery Interpretation: The length of wait for elective total hip arthroplasty is not associated with postoperative HRQOL and mobility However, patients who undergo the procedure within 6 months after referral have greater disability at referral, and realize greater gains in HRQOL and mobility after surgery, than patients waiting more than 6 months Clinically important losses in HRQOL and mobility occur in patients waiting more than 6 months

Engaging substance abusers after centralized assessment: predictors of treatment entry and dropout.

Abstract: High attrition continues to be an important issue for substance abuse treatment providers. This study examined factors contributing to treatment entry and dropout after referral from centralized assessment. Univariate analysis showed that individuals with a shorter wait after assessment were more likely to attend an initial treatment appointment, while those who reported a history of physical or sexual abuse or were on probation were significantly more likely to drop out of treatment early. Multivariate analysis revealed, first, that persons with a comorbid psychiatric diagnosis and those referred to outpatient rather than residential care were less likely to enter treatment; and, second, that persons on probation and with a history of physical or sexual abuse were more likely to be early treatment dropouts. Findings suggest that decisions to seek help and to accept help are distinct, and that program factors play a substantial role in treatment engagement and retention.

Family physicians' referral decisions: results from the ASPN referral study.

Abstract: OBJECTIVE To examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer. STUDY DESIGN Prospective cohort study. POPULATION All visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states. OUTCOMES MEASURED Rates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists. RESULTS Approximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician-gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist. CONCLUSIONS Referrals are commonly made during encounters other than office visits, such as telephone conversations or staff-patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

The dental home: A primary care oral health concept

Abstract: Background The pediatrics community has promoted the concept of a medical home to improve families' care utilization. The authors describe the medical home and propose a dental home concept to improve families' access to dental care. Description The dental home is a locus for preventive oral health supervision and emergency care. It can be a repository for records and the focus for making specialty referrals. When culture and ethnicity are barriers to care, the dental home offers a site adapted to care delivery and is sensitive to family values. Clinical Implications The dental home can provide access to preventive and emergency services for children. Establishment of the home early in the child's life can expose a child to prevention and early intervention before problems occur, reduce anxiety and facilitate referral.

The Biopsychosocial Revolution: Interviewing and Provider-patient Relationships Becoming Key Issues for Primary Care.

Abstract: George Engel proposed the biopsychosocial model in what soon became a landmark event for understanding medicine as a science.1,2* The model prompted a revolution in medical thinking by providing an argument and rationale that better linked medicine to science. Following the revolution in physics at the turn of the last century, science gradually moved away from previous linear, cause–effect thinking. To that point, understandably, medicine's guiding biomedical model focused only on diseases. Beginning with Engel's model, medical thinking has slowly evolved by incorporating and integrating psychosocial components. The biopsychosocial model stems from what many consider the modern articulation of science, general system theory.3–5 Engel's model prescribes a fundamentally different path from the still-guiding biomedical model: to be scientific, a model for medicine must include the psychosocial dimensions (personal, emotional, family, community) in addition to the biological aspects (diseases) of all patients. By integrating these multiple, interacting components of the subject of our science—the patient—we also become more humanistic. We link science and humanism. While this revolution/evolution in medicine has not yet supplanted the biomedical model, the biopsychosocial model now is taught in most medical schools, and most practitioners are familiar with the term and its meaning.6 But the problem we now face is that the model itself does not address the intricate process needed for achieving relevant biopsychosocial understanding of the patient. Identified by the Western Ontario group, “patient-centered” medicine developed as the approach (process) for implementing or operationalizing the biopsychosocial model.7–10 This new approach puts the patient's needs foremost (e.g., interests, concerns, questions, ideas, requests) but continues to include disease issues. Applied to the interview, we always integrate the patient-centered process with ‘doctor-centered’ interviewing (for disease details). By enhancing communication and provider-patient relationships (PPRs), patient-centered interviewing produces the relevant biopsychosocial reality of each patient at each visit. It changes the model from an intellectual construct to a practical means for a more scientific understanding of every patient. Patient-centered interviewing is the flip side of the biopsychosocial coin; they go hand-in-hand, process and content. Encompassing the dyadic patient-centered approach, newly described “relationship-centered” care (RCC) goes one step further.11,12 RCC extends the person-centered process to the remainder of the medical system, encouraging communication and relational principles at all levels, e.g., among administrators, nurses, doctors, and unions.13 This issue of the Journal of General Internal Medicine highlights the PPR and communication (and, therefore, the biopsychosocial model) in primary care research. For example, the work of Forrest et al. concerns the better understanding of some determinants of the PPR.14 They found that HMO patients rated the PPR lower when required to select a physician from a list and/or to get authorization for referral. The authors avoided the common pitfall of criticizing managed care and urging a change in its rules. Rather, while the HMO is doing its job to control continuously escalating costs,15 the authors acknowledge that the focus could profitably be upon the PPR itself (and, inextricably related, communication). This laudable position recognizes that the exigencies of managed care have increased already strong demands upon physicians to establish effective relationships and communication. The wisdom of focusing upon the PPR and not recommending simple administrative change can be found in a literature replete with the health outcome benefits of being patient-centered, many of which studies were randomized controlled trials; see reviews.16–18 The authors caution rightly that study other than their cross-sectional work will be needed to place their findings in proper perspective. For example, we do not know if administrative changes will have any impact on health without simultaneously addressing communication/PPR. Heisler et al. did not directly study the PPR but evaluated closely related communication-based predictors: patients’ perceptions of participatory decision making, informing patients, and understanding.19 They found that self-reported, improved outcomes of diabetes self-management were closely related to informing patients and, not surprisingly, to patient understanding. Informing and motivating patients are key patient-centered interviewing skills. But understanding alone is not sufficient, particularly where the patient may need to make unwanted changes, such as to begin a diet or quit smoking. For example, the following additional factors, among others, can also affect outcomes: specific PPR variables (e.g., empathy, open-ended inquiry), self-efficacy, satisfaction, compliance, cognitive ability, stress level, autonomy, and readiness to change. While the authors’ caveats about a cross-sectional study are germane, we applaud their addition to the increasing body of research indicating that patients benefit from being informed. We may think we provide sufficient information, but patients typically disagree20–22 and, perhaps with the stress of their illnesses, they often forget information they do receive.23 These papers, and several others in this issue, underscore the central role of communication and PPR in primary care and, therefore, the need to train students and physicians in patient-centered interviewing methods. While it is encouraging that more training now occurs, we need much more teaching for both students6 and residents.24 Although we have effective patient-centered interviewing methods, the need to teach them remains, especially for those beyond residency training, who often have had little previous exposure. For continuing medical education and faculty development, a wonderful resource has evolved (nurtured by the Society of General Internal Medicine) over the last 2 decades and has been a unique, valuable dissemination mechanism: The American Academy on Physician and Patient (AAPP) (www.physicianpatient.org). AAPP provides week-long training at its annual meeting (June) and also frequently conducts 1- to 2-day training sessions throughout the United States, always tailored to the needs and interests of those who invite them. The amount as well as the quality of research about PPR/communication in this issue can encourage us. These works provide testimony to our increasing focus upon the psychosocial aspects of primary care and to moving beyond an isolated interest in disease. Continuing to painstakingly generate sound evidence for psychosocial medicine fosters a needed maturation of this newer aspect of medicine—a prerequisite for the blossoming of a more scientific medicine.

Patient, hospital, and general practitioner characteristics associated with non-attendance: a cohort study.

Abstract: Studies examining characteristics of non-attendance at hospital outpatients have given inconsistent results. We examined a cohort of 1972 referrals from 26 general practitioners, with complete follow-up. Five factors were found to be significantly associated with non-attendance: male sex, younger age, longer interval between referral and appointment, higher Jarman score and patients of a high-referring general practitioner. Targeting of strategies to reduce non-attendance is possible using these results.

Pathways to care in children at risk of attention-deficit hyperactivity disorder

Abstract: Background There is underdiagnosis of and low use of specialist services for attention-deficit hyperactivity disorder (ADHD). Aims To quantify the filters in the help-seeking pathway through primary care and to investigate factors influencing progress for children at risk of ADHD. Method A total of 127 children (5-11 years old) with pervasive hyperactivity who passed each filter (primary care attendance and general practitioner (GP) recognition of disorder) were compared with those who had not. Results Primary care attendance was only associated with parental perception of the behaviour as problematic (OR 2.11; 95% CI 1.11-4.03). However, GP recognition was related to both parent and child factors — parental request for referral (OR 20.83; 95% CI 3.05-142.08) and conduct problems (OR 1.48; 95% CI 1.04-2.12). GP non-recognition was the main barrier in the pathway to care; following recognition, most children were referred. Conclusions Parents can be regarded as the main gatekeepers for access to specialist services.

Effects of respite care for children with developmental disabilities: evaluation of an intervention for at risk families.

Abstract: Respite child care programs that provide temporary child care, support, and referral services to families of children with developmental disabilities are thought to be a critical component of formal social support interventions deemed necessary to promote healthy family functioning and prevent child maltreatment. This study describes sociodemographic characteristics, parenting stress levels, foster care placement, and founded child maltreatment rates in families of children with developmental disabilities who were using respite care services in a rural Midwestern state. Comparison of matched pre- and post-test Parenting Stress Index scores indicated significant decreases in Total Stress scores (t=3.27, df=86, p=0.0016), Parent Domain scores (t=3.55, df=86, p=0.0006), and Child Domain scores (t=2.2, df=86, p=0.02) following provision of respite care. Through logistic regression, it was determined that life stress, social support, and service level were significantly related to the occurrence of child maltreatment during enrollment ( p < 0.05). The investigator suggests that public health nurses can enhance their case management strategies when working with the parents of children with developmental disabilities by monitoring for caregiver burnout in addition to ensuring that the child is receiving care appropriate for his or her level of need.