Showing papers on "Referral published in 2003"

Treating depression in predominantly low-income young minority women: a randomized controlled trial.

Abstract: ContextImpoverished minority women experience a higher burden from depression than do white women because they are less likely to receive appropriate care. Little is known about the effectiveness of guideline-based care for depression with impoverished minority women, most of whom do not seek care.ObjectiveTo determine the impact of an intervention to deliver guideline-based care for depression compared with referral to community care with low-income and minority women.Design, Setting, and ParticipantsA randomized controlled trial conducted in the Washington, DC, suburban area from March 1997 through May 2002 of 267 women with current major depression, who attended county-run Women, Infants, and Children food subsidy programs and Title X family planning clinics.OutcomesHamilton Depression Rating Scale measured monthly from baseline through 6 months; instrumental role functioning (Social Adjustment Scale) and social functioning (Short Form 36-Item Health Survey) measured at baseline and 3 and 6 months.InterventionsParticipants were randomly assigned to an antidepressant medication intervention (trial of paroxetine switched to bupropion, if lack of response) (n = 88), a psychotherapy intervention (8 weeks of manual-guided cognitive behavior therapy) (n = 90), or referral to community mental health services (n = 89).ResultsBoth the medication intervention (P<.001) and the psychotherapy intervention (P = .006) reduced depressive symptoms more than the community referral did. The medication intervention also resulted in improved instrumental role (P = .006) and social (P = .001) functioning. The psychotherapy intervention resulted in improved social functioning (P = .02). Women randomly assigned to receive medications were twice as likely (odds ratio, 2.04; 95% confidence interval, 0.98-4.27; P = .057) to achieve a Hamilton Depression Rating Scale score of 7 or less by month 6 as were those referred to community care.ConclusionsGuideline-concordant care for major depression is effective for these ethnically diverse and impoverished patients. More women engaged in a sufficient duration of treatment with medications compared with psychotherapy, and outcome gains were more extensive and robust for medications.

Diagnostic Accuracy of Stroke Referrals From Primary Care, Emergency Room Physicians, and Ambulance Staff Using the Face Arm Speech Test

Abstract: Background and Purpose— Timely referral of appropriate patients to acute stroke units is necessary for effective provision of skilled care. We compared the characteristics of referrals with suspect...

A Discussion of Chain Referral As a Method of Sampling Hard-to-Reach Populations:

Abstract: Nursing research often requires inquiry into sensitive topics that involve hidden or hard- to reach populations. However, identifying and sampling these populations for research purposes is often fraught with difficulties. Barriers include society's lack of tolerance of diverse groups, social stigma, concern for issues of confidentiality, and fear of exposure because of possible threats to security. Chain referral sampling techniques are proposed to minimize bias while maintaining privacy and confidentiality. Techniques of chain referral sampling are detailed for use in researching sensitive topics and hidden populations. When carefully planned and executed, this sampling design offers transcultural nurse researchers a reasonable method for accessing and studying special populations that are particularly hard-to-reach.

Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study.

Abstract: Objectives To determine the effect of the critical care outreach team on patient survival to discharge from hospital after discharge from critical care and readmission to critical care. Design Non-randomised population based study. Setting Tertiary referral teaching hospital with 1200 beds. Participants Patients discharged from the critical care unit after their first or only admission for two study periods, 26 February 2000 to 25 February 2001 and 26 February 2001 to 25 February 2002. Main outcome measures Survival to discharge from hospital after discharge from critical care and readmission to critical care. Results The introduction of a critical care outreach team improved survival to discharge from hospital after discharge from critical care by 6.8% (risk ratio 1.08). Readmission to critical care decreased by 6.4% (0.48). Conclusions The activity of the critical care outreach team seems to improve patient survival to discharge from hospital and may reduce the number of readmissions to critical care.

Symptoms in 400 patients referred to palliative care services: prevalence and patterns.

Abstract: The demographics and prevalence of symptoms in patients at first referral to the different components of palliative care services were identified by a retrospective case note study of 400 patients referred to three palliative care centres in London, UK: Michael Sobell House, Mount Vernon Hospital; The North London Hospice; St Bartholomew's and the Royal London Hospitals. One hundred consecutive referrals to each of the following service components were analysed: a hospice inpatient service; a community team; an NHS hospital support team and an outpatient service. A standardized proforma was used to collect the data. Ninety five per cent (380/400) of patients referred had a cancer diagnosis. The five most prevalent symptoms overall were pain (64%), anorexia (34%), constipation (32%), weakness (32%) and dyspnoea (31%), which is similar to other published reports. However, the commonest symptoms and their prevalence varied depending on the service component to which the patient was referred. Patients referre...

Ethnicity and differential access to care for eating disorder symptoms.

Abstract: Objective The impact of ethnicity on access to health care for eating disorder symptoms among participants in the 1996 National Eating Disorders Screening Program (NEDSP) was examined in two studies. Method Self-report and clinician-assessed data were analyzed from 9,069 participants in an educational and two-stage screening program for eating disorders in Study I. In Study II, both cross-sectional and prospective data from a randomly selected sample of 289 participants from the same program were analyzed to investigate the impact of ethnic minority status on both help-seeking patterns and clinician referral patterns for eating disorder symptoms. Results Even after controlling for severity of self-reported eating disorder symptoms, both Latino and Native American participants in the NEDSP were significantly less likely than Whites to receive a recommendation or referral for further evaluation or care. Ethnic minority subjects with self-acknowledged eating and weight concerns were also significantly less likely than non-minority participants to have been asked by a doctor about eating disorder symptoms. Only one marginally significant difference was found between ethnic minority and non-minority respondents with respect to their help-seeking behaviors, namely, ethnic minority subjects were less likely (at the level of a trend) to seek eating disorders treatment within 1½–2 years following the NEDSP. Discussion These data suggest that clinician bias may be an important barrier to access to care for eating disorder symptoms in ethnic minority populations. © 2003 by Wiley Periodicals, Inc. Int J Eat Disord 33: 205–212, 2003.

Problem‐Solving Model for Decision Making with High‐Incidence Disabilities: The Minneapolis Experience

Abstract: The problem-solving model (PSM) is used in the Minneapolis Public Schools to guide decisions regarding: (1) interventions in general education, (2) referral to special education, and (3) evaluation for special education eligibility for high-incidence disability areas. District implementation was driven by four themes: the appropriateness of intelligence tests and the IQ-achievement discrepancy for determination of eligibility, bias in assessment, allocation of school psychologist time, and linking assessment to instruction through curriculum-based measurement. This article describes how the PSM was designed as a three-stage process to measure response to intervention and used in the special education eligibility process. Program evaluation data collected since initial implementation in 1994 is reported in the areas of child count, achievement, referral, eligibility, and disproportion. The authors discuss the limitations of conducting PSM research in school settings, barriers to implementation of PSM, and make suggestions for enhancing treatment integrity.

Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: a cross-national, cross-clinic comparative analysis.

Abstract: This study examined demographic characteristics, social competence, and behavior problems in clinic-referred children with gender identity problems in Toronto, Canada (N = 358), and Utrecht, The Netherlands (N = 130) The Toronto sample was, on average, about a year younger than the Utrecht sample at referral, had a higher percentage of boys, had a higher mean IQ, and was less likely to be living with both parents On the Child Behavior Checklist (CBCL), both groups showed, on average, clinical range scores in both social competence and behavior problems A CBCL-derived measure of poor peer relations showed that boys in both clinics had worse ratings than did the girls A multiple regression analysis showed that poor peer relations were the strongest predictor of behavior problems in both samples This study-the first cross-national, cross-clinic comparative analysis of children with gender identity disorder-found far more similarities than differences in both social competence and behavior problems The most salient demographic difference was age at referral Cross-national differences in factors that might influence referral patterns are discussed

Referral Rates for Intervention or Assessment A Meta-Analysis of Racial Differences

Abstract: This study synthesized the literature on the rates of referral for intervention or assessment of students from three racial groups: Caucasian, African American, and Hispanic. Ten studies, published or unpublished, that presented frequency counts for the population and the referred sample for at least one school district yielded 44 comparisons. For comparisons between African American and Caucasian students, the mean risk ratios comparing the referral rates were significantly different from zero. No significant differences were found between the referral rates of Hispanic students and Caucasian students. Implications, limitations, and directions for future research are presented.

Access to specialty medical care for children with mental retardation, autism, and other special health care needs.

Abstract: Access to specialty medical care among children with mental retardation, autism, or other types of special health care needs was examined. Results from a national survey indicate that over a third of the children with autism, over a fifth with mental retardation, and over a fifth with other types of special health care needs had problems obtaining needed care from specialty doctors in the preceding year. The most common problems included getting referrals and finding providers with appropriate training. Children with unstable health conditions, autism, or those whose parent was in poor health were at greater risk for problems. Primary Medicaid coverage and public secondary health coverage were associated with fewer access problems. Implications for health services for children with special health care needs are discussed.

Primary care in the United States: primary care gatekeeping and referrals: effective filter or failed experiment?

Abstract: The use of primary care physicians as gatekeepers to specialists and other medical resources—considered to be a managed care innovation in the United States—has proliferated during the past few decades. Its introduction has been accompanied by a government sponsored programme of research into referrals from primary care (box 1). Findings from these studies may offer insights into how the UK's NHS could shape the gatekeeping function of general practitioners. This article discusses the concept of gatekeeping, contrasts the processes of referral to specialists in the United States and the United Kingdom, examines the mechanisms by which gatekeeping influences resource allocation, and discusses the effects of linking gatekeeping with financial incentives and utilisation review. #### Summary points Gatekeeping systems have emerged in countries with scarce medical resources Gatekeepers ensure equity by judiciously matching healthcare services, including specialty referrals, to healthcare needs Gatekeeping alters patients' behaviour, increasing levels of first contact care with primary care physicians, thereby reducing patients' self referrals Patients in US health plans with gatekeeping arrangements are twice as likely to be referred to specialist care as their UK counterparts There is little evidence that gatekeeping has had much effect on patients' referral rates in the United States, a healthcare environment rich in specialists Within modern societies, gatekeepers are positioned between organisations and individuals who wish to use resources within those organisations. Gatekeepers use discretion when determining who will be granted access to these resources. Physician gatekeepers collaborate with patients to identify their healthcare needs and choose services that effectively meet those needs. Public acceptance of gatekeeping is strengthened when there are too few resources to satisfy everyone's demands. In the United Kingdom, where long queues to see specialists are common because specialists are in short supply, the general practitioner gatekeeper has enjoyed widespread support. In the United States, the public perceives …

Survey of Physician Attitudes and Practices Related to Pediatric Obesity

Abstract: The purpose of this study was to survey physicians regarding their attitudes and practices related to the treatment of pediatric obesity in a primary care setting. Surveys were sent to physicians who were members of the American Academy of Pediatrics and the American Academy of Family Physicians practicing in the Southern New England area (Connecticut, Massachusetts, and Rhode Island). The 14-item survey consisted of three main areas of focus: attitudes toward obesity, treatment and referral approaches, and barriers to addressing weight concerns in children and adolescents. Physicians estimated that 27.7% of their adolescent and 23% of their child patients are overweight. The frequency with which physicians address weight issues with both child and adolescent patients appears to increase incrementally with the patient's level of overweight. When addressing obesity, one fourth of physicians think that they are not at all or only slightly competent, while 20% report feeling not at all or only slightly comfortable. These findings suggest that physicians would benefit from additional training and education regarding safe and efficacious intervention strategies for pediatric obesity, to effectively integrate the discussion of weight issues into the primary care setting.

How do patients choose physicians? Evidence from a national survey of enrollees in employment-related health plans.

Abstract: There is growing awareness of consumer and patient choices and their large impact on the ultimate cost and outcomes of health service use. This can occur directly through decisions to seek care, to comply with prescribed treatment regimens, or indirectly through choice of physicians who make treatment decisions jointly with or on behalf of patients. In theory, patients can play an important role in achieving optimal health by taking an active and informed role in treatment decisions and switching physicians if care is unsatisfactory. There is a wide consensus that the role of consumers in shaping the health care delivery system will expand over time with the recent decline of restrictive forms of managed care and rapid increases in the availability of health care information via the internet (Robinson 2001; Herzlinger 1997). In assessing the potential impact of this enhanced role, it is important to understand the process by which consumers evaluate and choose health care providers and treatments. Of particular importance is a better understanding of the role of health status in the consumer choice process. Individuals in poor health use the health care delivery system more frequently and intensively compared with their healthier counterparts. To the extent that providers compete to maintain and attract new patients, provider and treatment choices made by individuals in poor health will have a disproportionate effect on care processes. Likewise, those in poor health will experience disproportionate health and financial consequences of a consumer-driven health care system. This paper contributes to a greater understanding of the consumer choice process by examining patient choice of physician. Patients choose a practitioner each time they seek physician care. Sometimes the choice of a practitioner is explicit, for example, when a patient moves to a new area or chooses to leave an established relationship to join a health plan unaffiliated with his or her physician. Other times the choice is implicit, as in the case of a patient who continues to see the same physician or accepts a referral to a single physician without actively considering alternative practitioners. Literature suggests that patients do not engage in rational or “consumerist” behavior when searching for or choosing physicians. They instead rely heavily on recommendations from family and friends and engage in limited searches for alternative physicians (Hoerger and Howard 1995; Kaiser Family Foundation/Agency for Health Care Policy and Research 1996; Kaiser Family Foundation Agency for Health Care Research and Quality 2000; Lupton, Donaldson, and Lloyd 1997). The increasing availability of information with which to evaluate physician quality has the potential to make the process of choosing physicians more active by reducing the cost and time needed to assess the costs and benefits of seeking care from alternative practitioners. Little is known about the process by which patients search for and choose physicians. Studies to date have focused narrowly on the impact of physician attributes (e.g., gender, race, cost, specialty) (Saha et al. 2000; Weiss and Blustein 1996; Phillips and Brooks 1998; Kerssens, Bensing, and Andela 1997; Marquis 1984). The small number of studies focusing more generally on the choice process use highly selected samples of patients or data from a single geographic region or population subgroup (Hoerger and Howard, 1995; Lupton, Donaldson, and Lloyd 1997; Hibbard and Weeks 1987; Olsen, Kane, and Kasteler 1976; Booth and Babchuk 1972). This paper addresses this gap in the literature by examining several aspects of the process by which patients search for and choose physicians, using data from a survey administered to a random sample drawn from a nationally representative panel of households. Specifically, this study uses a wide range of patient characteristics to predict (1) the use of information to support the choice of current physician, (2) the serious consideration of another doctor prior to choosing a physician, and (3) the stated willingness to switch physicians when presented with information that suggests other health plan physicians received higher quality ratings.

Prevention of early childhood caries in North Carolina medical practices: implications for research and practice.

Abstract: Early childhood caries is a significant public health problem in low-income children, with important negative consequences for the child and the family. The purpose of this paper is to describe the development, implementation, and preliminary outcomes of preventive dentistry programs in North Carolina that target low-income children from birth to thirty-five months of age. The focus is on Into the Mouths of Babes, a statewide program in which pediatricians, family physicians, and providers in community health clinics are reimbursed by Medicaid to provide preventive dental services for children (risk assessment, screening, referral, fluoride varnish application) and caregivers (counseling). The provider intervention includes continuing medical education lectures and interactive sessions, practice guidelines for the patient interventions, case-based problems, practical strategies for implementation, a toolkit with resource materials, and follow-up training. In the first two years of the statewide program, 1,595 medical providers have been trained. The number of providers billing for these services has steadily increased, and by the last quarter of 2002, the number of visits in which preventive dental services were provided in medical offices reached 10,875. A total of 38,056 preventive dental visits occurred in medical offices in 2002. By the end of 2002, only sixteen of the state9s one hundred counties had no pediatrician, family physician, or local health department participating. The preliminary results from this program demonstrate that nondental professionals can integrate preventive dental services into their practices. The program has increased access to preventive dental services for young Medicaid children whose access to dentists is restricted. Assessments of effectiveness and cost-effectiveness of both the provider and patient interventions are under way.

School Refusal in Children and Adolescents

Abstract: School refusal is a problem that is stressful for children, families, and school personnel. Failing to attend school has significant short- and long-term effects on children's social, emotional, and educational development. School refusal often is associated with comorbid psychiatric disorders such as anxiety and depression. It is important to identify problems early and provide appropriate interventions to prevent further difficulties. Assessment and management of school refusal require a collaborative approach that includes the family physician, school staff, parents, and a mental health professional. Because children often present with physical symptoms, evaluation by a physician is important to rule out any underlying medical problems. Treatments include educational-support therapy, cognitive behavior therapy, parent-teacher interventions, and pharmacotherapy. Family physicians may provide psychoeducational support for the child and parents, monitor medications, and help with referral to more intensive psychotherapy.

Markers of Access to and Quality of Primary Care for Aboriginal People in Ontario, Canada

Abstract: Objectives. We evaluated primary care accessibility and quality for Ontario’s aboriginal population. Methods. We compared a defined aboriginal cohort with nonaboriginal populations with analogous geographic isolation and low socioeconomic status. We determined rates of hospitalization for the following indicators of adequacy of primary care: ambulatory care–sensitive (ACS) conditions and utilization of referral care–sensitive (RCS) procedures from administrative databases. Results. ACS hospitalization rates, relative to the general population, were 2.54, 1.50, and 1.14 for the aboriginal population, the geographic control populations, and the socioeconomic control populations, respectively. The relative RCS procedure utilization rates were 0.64, 0.91, and 1.00, respectively. Conclusions. The increased ACS hospitalization rate and reduced RCS procedure utilization rate suggest that northern Ontario’s aboriginal residents have insufficient or ineffective primary care.

Mental disorders in primary care.

Abstract: Current estimates indicate that 50% of the population experience at least one mental disorder in their lifetime and that at least 25% have suffered a mental disorder in the past year. recognition, diagnosis, treatment, and referral depend overwhelmingly on general practitioners, at least one third of whose consultations have a direct and explicit psychological component. Yet despite this intensive familiarization with the presentation of mental pathology, and the appropriateness of the primary care setting to its management, even the most recent surveys indicate that performance is best described by the rule of diminishing halves: only half the patients with a thresh-old disorder are recognized; only half of those recognized are treated; and only half of those treated are effectively treated. There is no single solution to this problem, only multiple solutions, which must be aimed, consistently and simultaneously, at the patient, practitioner, practice, and research levels.

A smoking cessation intervention for parents of children who are hospitalized for respiratory illness: the stop tobacco outreach program.

Abstract: Objective Parental smoking is associated with increased rates and severity of childhood respiratory illness. No previous studies have examined child hospitalization as an opportunity for parental smoking cessation. We evaluated the feasibility of implementing a smoking cessation intervention for parents at the time of child hospitalization for respiratory illness. Methods We performed a prospective cohort study of smoking parents who had a child who was admitted to an academic children's hospital for a respiratory illness between January and April 2000. All enrollees were offered the Stop Tobacco Outreach Program, which includes an initial motivational interview, written materials, nicotine replacement therapy (NRT), telephone counseling, and fax referral to parents' primary clinician. The primary outcome was completion of all 3 counseling sessions. Two-month follow-up outcomes were quit attempts, cessation, NRT use, primary care visits, household smoking prohibition, and satisfaction. Results A total of 126 smoking parents met eligibility criteria, and 71 (56%) enrolled in the study. Of the 71, 80% completed all counseling sessions and 56% accepted free NRT at the time of enrollment. At the 2-month follow-up, of the 71 initial enrollees, 49% reported having made a quit attempt that lasted at least 24 hours, 21% reported not smoking a cigarette in the last 7 days, 27% reported having used NRT, and 38% had had a visit with their own primary clinician. The proportion of parents who reported rules prohibiting smoking in the house increased (29% vs 71%). Parental rating of the overall usefulness of the program was 4.3 +/- 0.9 (1 standard deviation) on the 5-point scale 1 = not at all and 5 = a great extent. Conclusions This study demonstrates the feasibility of engaging parents in smoking cessation interventions at the time of child hospitalization for respiratory illness. Previous work done in a similar sample of parental smokers has shown extremely low ever-use rates of cessation programs. High rates of acceptance of in-hospital and telephone counseling in this study support the notion of child hospitalization as a teachable moment to address parental smoking.

The experience of lower limb lymphedema for women after treatment for gynecologic cancer.

Abstract: Purpose/objectives To describe women's experiences with lower limb lymphedema to inform both preventive and management clinical practices. Design A retrospective survey. Setting The gynecology/oncology unit of a tertiary referral women's hospital in Australia. Sample 82 women who developed lower limb lymphedema after surgical and radiation treatment for gynecologic cancers. Methods Structured interviews. Main research variables Psychosocial and emotional impact, physical effects, knowledge, support, treatment modalities. Findings Women identified changes in appearance and sensation in the legs and the triggers that both preceded and exacerbated symptoms. Women described seeking help and receiving inappropriate advice with as many as three assessments prior to referral to lymphedema specialists. Many women implemented self-management strategies. Lower limb lymphedema had an impact on appearance, mobility, finances, and self-image. Conclusions Increasing longevity after gynecologic oncology treatment requires all practitioners to be aware of known or potential triggers of lower limb lymphedema and the appropriate referral and management strategies available. Women at risk need to know early signs and symptoms and where to seek early care. Implications for nursing The role of nursing in acute and community care of women at risk for developing lower limb lymphedema includes (a) engaging women in protecting their legs from infection or trauma pre- and postoperatively, (b) providing nursing care and education during the pre- and postoperative phases, and (c) ensuring that women being discharged are aware of early signs and symptoms of lower limb lymphedema and how to access qualified, specialized therapists so that early and effective management can be initiated.

Direct observation of requests for clinical services in office practice: what do patients want and do they get it?

Abstract: Background Requests can influence the conduct and content of the medical visit. However, little is known about the nature, frequency, and impact of such requests. We performed this study to ascertain the prevalence, antecedents, and consequences of patients' requests for clinical services in ambulatory practice. Methods This observational study combined patient and physician surveys with audiotaping of 559 visits to 45 physicians in 2 health care systems between January and November 1999. All patients had a new problem or significant health concern. Main outcome measures included prevalence of 8 categories of requests for physician action; odds of patients' requesting tests, referrals, or new prescriptions; odds of physicians' ordering diagnostic tests, making specialty referrals, or writing new prescriptions; patient satisfaction; and physicians' perceptions of the visit. Results The 559 patients made 545 audiocoded requests for physician action; 23% requested at least 1 diagnostic test, specialty referral, or new prescription medication. Requests for diagnostic tests were more common among new patients (P Conclusions Though more common in primary care than in cardiology, patients' requests for clinical services are both pervasive and influential. The results support placing greater emphasis on understanding and addressing the patient's role in determining health care utilization.