Showing papers on "Referral published in 2007"

Internet-based customer referral system

Abstract: Disclosed is an Internet-based referral system that enables individuals and other business entities ("associates") to market products, in return for a commission, that are sold from a merchant's Web site. The system includes automated registration software that runs on the merchant's Web site to allow entities to register as associates. Following registration, the associate sets up a Web site (or other information dissemination system) to distribute hypertextual catalog documents that includes marketing information (product reviews, recommendations, etc.) about selected products of the merchant. In association with each such product, the catalog document includes a hypertextual "referral link" that allows a user ("customer") to link to the merchant's site and purchase the product. When a customer selects a referral link, the customer's computer transmits unique IDs of the selected product and of the associate to the merchant's site, allowing the merchant to identify the product and the referring associate. If the customer subsequently purchases the product from the merchant's site, a commission is automatically credited to an account of the referring associate. The merchant site also implements an electronic shopping cart that allows the customer to select products from multiple different Web sites, and then perform a single "check out" from the merchant's site.

Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war.

Abstract: ContextTo promote early identification of mental health problems among combat veterans, the Department of Defense initiated population-wide screening at 2 time points, immediately on return from deployment and 3 to 6 months later. A previous article focusing only on the initial screening is likely to have underestimated the mental health burden.ObjectiveTo measure the mental health needs among soldiers returning from Iraq and the association of screening with mental health care utilization.Design, Setting, and ParticipantsPopulation-based, longitudinal descriptive study of the initial large cohort of 88 235 US soldiers returning from Iraq who completed both a Post-Deployment Health Assessment (PDHA) and a Post-Deployment Health Re-Assessment (PDHRA) with a median of 6 months between the 2 assessments.Main Outcome MeasuresScreening positive for posttraumatic stress disorder (PTSD), major depression, alcohol misuse, or other mental health problems; referral and use of mental health services.ResultsSoldiers reported more mental health concerns and were referred at significantly higher rates from the PDHRA than from the PDHA. Based on the combined screening, clinicians identified 20.3% of active and 42.4% of reserve component soldiers as requiring mental health treatment. Concerns about interpersonal conflict increased 4-fold. Soldiers frequently reported alcohol concerns, yet very few were referred to alcohol treatment. Most soldiers who used mental health services had not been referred, even though the majority accessed care within 30 days following the screening. Although soldiers were much more likely to report PTSD symptoms on the PDHRA than on the PDHA, 49% to 59% of those who had PTSD symptoms identified on the PDHA improved by the time they took the PDHRA. There was no direct relationship of referral or treatment with symptom improvement.ConclusionsRescreening soldiers several months after their return from Iraq identified a large cohort missed on initial screening. The large clinical burden recently reported among veterans presenting to Veterans Affairs facilities seems to exist within months of returning home, highlighting the need to enhance military mental health care during this period. Increased relationship problems underscore shortcomings in services for family members. Reserve component soldiers who had returned to civilian status were referred at higher rates on the PDHRA, which could reflect their concerns about their ongoing health coverage. Lack of confidentiality may deter soldiers with alcohol problems from accessing treatment. In the context of an overburdened system of care, the effectiveness of population mental health screening was difficult to ascertain.

Screening, Brief Intervention, and Referral to Treatment (SBIRT): Toward a Public Health Approach to the Management of Substance Abuse.

Abstract: Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive and integrated approach to the delivery of early intervention and treatment services through universal screening for persons with substance use disorders and those at risk. This paper describes research on the components of SBIRT conducted during the past 25 years, including the development of screening tests, clinical trials of brief interventions and implementation research. Beginning in the 1980s, concerted efforts were made in the US and at the World Health Organization to provide an evidence base for alcohol screening and brief intervention in primary health care settings. With the development of reliable and accurate screening tests for alcohol, more than a hundred clinical trials were conducted to evaluate the efficacy and cost effectiveness of alcohol screening and brief intervention in primary care, emergency departments and trauma centers. With the accumulation of positive evidence, implementation research on alcohol SBI was begun in the 1990s, followed by trials of similar methods for other substances (e.g., illicit drugs, tobacco, prescription drugs) and by national demonstration programs in the US and other countries. The results of these efforts demonstrate the cumulative benefit of translational research on health care delivery systems and substance abuse policy. That SBIRT yields short-term improvements in individuals' health is irrefutable; long-term effects on population health have not yet been demonstrated, but simulation models suggest that the benefits could be substantial.

The NCCN Guideline for Distress Management: A Case for Making Distress the Sixth Vital Sign

Abstract: Psychosocial care of patients has traditionally been seen as separate from routine medical care and has been criticized as being “soft” and lacking evidence. This traditional perspective continues in many settings, despite the fact that patients and families, when asked, state that emotional care is highly valued. The question of how to integrate psychosocial care into routine cancer care has also been an issue, partly because of the stigma associated with cancer. In 1997, the National Comprehensive Cancer Network (NCCN) established a multidisciplinary panel to examine this problem. 1 Because patient and physician attitudes toward pain can pose similar barriers to care as with distress, the panel used as a model the rating system for assessing pain that resulted in successful improvement of pain management in the United States. The rating system’s success seemed partly based on routinely using a single question to assess a patient’s pain: “How is your pain on a scale of 0 to 10?” The system uses a score of 5 or higher as the indication to reassess pain medications or refer the patient for more expert management. This system is widely used, and patient self-report of subjective symptoms is now accepted as appropriate and reliable. Pain has become the fifth vital sign, after pulse, respiration, blood pressure, and temperature, ensuring that it is evaluated as part of routine care. Drawing on this experience, the NCCN panel recommended a simple question to ask patients about psychosocial concerns. They found that distress was the best umbrella word to represent the range of emotional concerns patients with cancer experience and that it did not carry the stigma of other words sometimes used for emotional symptoms. Several studies have now validated the approach of asking, “How is your distress on a scale of 0 to 10?” and using a score of 4 or above as the trigger for further questions and possible referral to a psychosocial service. 2,3 In 2004, the Canadian Federal Government’s public health agency, Health Canada‐Canadian Strategy for Cancer Control, approved “Emotional Distress as the 6th Vital Sign.” 4 We propose that this system should also be considered in the United States to ensure that psychosocial distress is routinely assessed as part of cancer care and managed according to the NCCN distress management guidelines. This commentary outlines the potential benefits that can accrue for patients, families, and the health care system. Over 2 years beginning in 1997, the NCCN’s multidisciplinary panel de

A Penny for Your Thoughts: Referral Reward Programs and Referral Likelihood:

Abstract: Because referral reward programs reward existing customers and build the customer base, firms use them to encourage customers to make recommendations to others The authors report on four experiments in which they find that rewards increase referral likelihood More specifically, they find that rewards are particularly effective in increasing referral to weak ties and for weaker brands It is also important who receives the reward Overall, for weak ties and weaker brands, giving a reward to the provider of the recommendation is important For strong ties and stronger brands, providing at least some of the reward to the receiver of the referral seems to be more effective The authors discuss the implications of the results for the design of reward programs

Cost-effectiveness of systematic depression treatment among people with diabetes mellitus

Abstract: Context Depression co-occurring with diabetes mellitus is associated with higher health services costs, suggesting that more effective depression treatment might reduce use of other medical services. Objective To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among outpatients with diabetes. Design Randomized controlled trial comparing systematic depression treatment program with care as usual. Setting Primary care clinics of group-model prepaid health plan. Patients A 2-stage screening process identified 329 adults with diabetes and current depressive disorder. Intervention Specialized nurses delivered a 12-month, stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program. Subsequent treatment (combining psychotherapy and medication, adjustments to medication, and specialty referral) was adjusted according to clinical response. Main Outcome Measures Depressive symptoms were assessed by blinded telephone assessments at 3, 6, 12, and 24 months. Health service costs were assessed using health plan accounting records. Results Over 24 months, patients assigned to the intervention accumulated a mean of 61 additional days free of depression (95% confidence interval [CI], 11 to 82 days) and had outpatient health services costs that averaged $314 less (95% CI, $1007 less to $379 more) compared with patients continuing in usual care. When an additional day free of depression is valued at $10, the net economic benefit of the intervention is $952 per patient treated (95% CI, $244 to $1660). Conclusions For adults with diabetes, systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective. Depression screening and systematic depression treatment should become routine components of diabetes care.

AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services.

Abstract: Endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons

Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review.

Abstract: Background Despite the health benefits of physical activity, most adults do not take the recommended amount of exercise. Aim To assess whether exercise-referral schemes are effective in improving exercise participation in sedentary adults. Design of study Systematic review. Method Studies were identified by searching MEDLINE, CINAHL, EMBASE, AMED, PsycINFO, SPORTDiscus, The Cochrane Library and SIGLE until March 2007. Randomised controlled trials (RCTs), observational studies, process evaluations and qualitative studies of exercise-referral schemes, defined as referral by a primary care clinician to a programme that encouraged physical activity or exercise were included. RCT results were combined in a meta-analysis where there was sufficient homogeneity. Results Eighteen studies were included in the review. These comprised six RCTs, one non-randomised controlled study, four observational studies, six process evaluations and one qualitative study. In addition, two of the RCTs and two of the process evaluations incorporated a qualitative component. Results from five RCTs were combined in a meta-analysis. There was a statistically significant increase in the numbers of participants doing moderate exercise with a combined relative risk of 1.20 (95% confidence intervals = 1.06 to 1.35). This means that 17 sedentary adults would need to be referred for one to become moderately active. This small effect may be at least partly due to poor rates of uptake and adherence to the exercise schemes. Conclusion Exercise-referral schemes have a small effect on increasing physical activity in sedentary people. The key challenge, if future exercise-referral schemes are to be commissioned by the NHS, is to increase uptake and improve adherence by addressing the barriers described in these studies.

Effectiveness of shared care across the interface between primary and specialty care in chronic disease management

Abstract: Background Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than either primary or specialty care alone. It has been defined as the joint participation of primary care physicians and specialty care physicians in the planned delivery of care, informed by an enhanced information exchange over and above routine discharge and referral notices. It has the potential to offer improved quality and coordination of care delivery across the primary-specialty care interface and to improve outcomes for patients. Objectives To determine the effectiveness of shared-care health service interventions designed to improve the management of chronic disease across the primary-specialty care interface. Search methods We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (and the database of studies awaiting assessment); Cochrane Central Register of Controlled Trials (CENTRAL); Database of Abstracts of Reviews of Effects (DARE); MEDLINE (from 1966); EMBASE (from 1980) and CINAHL (from 1982). We also searched the reference lists of included studies. Selection criteria Randomised controlled trials, controlled before and after studies and interrupted time series analyses of shared-care interventions for chronic disease management. The participants were primary care providers, specialty care providers and patients. The outcomes included physical health outcomes, mental health outcomes, and psychosocial health outcomes, treatment satisfaction, measures of care delivery including participation in services, delivery of care and prescribing of appropriate medications, and costs of shared care. Data collection and analysis Three review authors independently assessed studies for eligibility, extracted data and assessed study quality. Main results Twenty studies of shared care interventions for chronic disease management were identified, 19 of which were randomised controlled trials. The majority of studies examined complex multifaceted interventions and were of relatively short duration. The results were mixed. Overall there were no consistent improvements in physical or mental health outcomes, psychosocial outcomes, psychosocial measures including measures of disability and functioning, hospital admissions, default or participation rates, recording of risk factors and satisfaction with treatment. However, there were clear improvements in prescribing in the studies that considered this outcome. The methodological quality of studies varied considerably with only a minority of studies of high-quality design. Cost data were limited and difficult to interpret across studies. Authors' conclusions This review indicates that there is, at present, insufficient evidence to demonstrate significant benefits from shared care apart from improved prescribing. Methodological shortcomings, particularly inadequate length of follow-up, may partially account for this lack of evidence. This review indicates that there is no evidence to support the widespread introduction of shared care services at present. Future shared-care interventions should only be developed within research settings and with account taken of the complexity of such interventions and the need to carry out longer studies to test the effectiveness and sustainability of shared care over time.

Behavioral and psychosocial interventions in diabetes: a conceptual review.

Abstract: A major task of diabetes care providers is to support patients in performing necessary self-care behaviors using well-accepted strategies such as recommending effective self-care regimens and educating patients in their use. Also critical are behavioral interventions that help patients implement self-care regimens in the face of life's exigencies. The purpose of this article is to identify key behavioral/psychosocial interventions available to diabetes care providers. We present a conceptual framework for organizing the application of these interventions, focusing on practical interventions that can be implemented by a typical health care provider, including referral to a behavioral/psychosocial specialist where this seems the most practical choice. A typical office visit lasts only 15 min (1). Therefore, feasibility is an important consideration in evaluating patient care recommendations. The strategies we propose should be no more time-consuming than these approaches, which are highly recommended for their feasibility. A previously demonstrated, effective counseling strategy for weight loss can be maintained by 15-min visits (2). A behavior change support approach, the 5As (ask, advise, assess, assist, arrange) Model, is estimated to take less than half the time of a normal office visit (3). An emotional support approach, the BATHE (background, affect, trouble, handling, empathy) Model, is estimated to take ∼15 min (4). Feasibility must also be assessed in terms of what it costs to ignore psychosocial problems or to employ an ineffective approach to behavior change. Patients who have psychological problems use health services more intensively, and if patients do not change their behavior, the clinician must spend time dealing with the problem at subsequent visits. Finally, research suggests that dealing with patients' concerns does not require additional time if done correctly (5). Thus, effective clinical procedure may also be efficient. The review we present is not exhaustive. We do not discuss all interventions that have …

Improving the management of family psychosocial problems at low-income children's well-child care visits: the WE CARE Project.

Abstract: OBJECTIVE: Our goal was to evaluate the feasibility and impact of an intervention on the management of family psychosocial topics at well-child care visits at a medical home for low-income children. PATIENTS AND METHODS: A randomized, controlled trial of a 10-item self-report psychosocial screening instrument was conducted at an urban hospital-based pediatric clinic. Pediatric residents and parents were randomly assigned to either the intervention or control group. During a 12-week period, parents of children aged 2 months to 10 years presenting for a well-child care visit were enrolled. The intervention components included provider training, administration of the family psychosocial screening tool to parents before the visit, and provider access to a resource book that contained community resources. Parent outcomes were obtained from postvisit and 1-month interviews, and from medical chart review. Provider outcomes were obtained from a self-administered questionnaire collected after the study. RESULTS: Two hundred parents and 45 residents were enrolled. Compared with the control group, parents in the intervention group discussed a significantly greater number of family psychosocial topics (2.9 vs 1.8) with their resident provider and had fewer unmet desires for discussion (0.46 vs 1.41). More parents in the intervention group received at least 1 referral (51.0% vs 11.6%), most often for employment (21.9%), graduate equivalent degree programs (15.3%), and smoking-cessation classes (14.6%). After controlling for child age, Medicaid status, race, educational status, and food stamps, intervention parents at 1 month had greater odds of having contacted a community resource. The majority of residents in the intervention group reported that the survey instrument did not slow the visit; 54% reported that it added <2 minutes to the visit. CONCLUSIONS: Brief family psychosocial screening is feasible in pediatric practice. Screening and provider training may lead to greater discussion of topics and contact of community family support resources by parents. Language: en

Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice

Abstract: OBJECTIVES. The purpose of this study was to investigate the effectiveness and costs of incorporating a parent-completed developmental screening tool, the Ages and Stages Questionnaire, into the 12- and 24-month well-child visits under “real-world” conditions, using a combined in-office and mail-back data collection protocol. METHODS. A convenience sample of 1428 caregivers and children presenting for their 12- or 24-month well-child visit between April 2005 and March 2006 participated. Children with identified delays or disorders were excluded. Board-certified pediatricians (n = 18) and nurse practitioners (n = 2) acted as secondary participants. Pediatricians were blinded to Ages and Stages Questionnaire results when completing the Pediatric Developmental Impression. Patients with delayed Ages and Stages Questionnaire or Pediatric Developmental Impression results were referred for additional evaluation. RESULTS. Referral rates increased by 224%. Pediatrician referral on the basis of the Pediatric Developmental Impression was predicted significantly by suspected communication delay and gross motor delay. The Ages and Stages Questionnaire and Pediatric Developmental Impression results differed significantly, with overall agreement of 81.8%. Of Ages and Stages Questionnaire–delayed cases, 67.5% were not detected by pediatricians. Of the 78 patients referred on the basis of combined Ages and Stages Questionnaire and Pediatric Developmental Impression results, 53 would not have been referred on the basis of Pediatric Developmental Impression results alone; 37 patients qualified for special services, and 44 were scheduled for additional developmental monitoring. The rate of Ages and Stages Questionnaire return by caregivers/parents was 54%. CONCLUSIONS. Referral rates increased dramatically, with the greatest increase at 12 months. Although patients with pediatrician referrals were likely to qualify for services (96%), physician referrals accounted for only 42% of total referrals, which highlights the need for pediatric developmental screening. The 54% Ages and Stages Questionnaire return rate, although acceptable under study conditions, calls for alternative implementation strategies.

Performance of referral recommendations in patients with chronic back pain and suspected axial spondyloarthritis

Abstract: Background: Ankylosing spondylitis (AS) and its early form account for up to 5% of all patients with chronic back pain. Interest has recently focused on shortening the delay of 5–10 years between the appearance of first symptoms and the diagnosis of AS, particularly because effective treatments have now become available. Referral parameters that are easy for doctors in primary care to apply to patients presenting with possible AS could contribute to earlier diagnosis. Methods: Orthopaedists and primary-care doctors were requested to refer patients with (1) chronic low back pain (duration >3 months) and (2) onset of back pain before Results: In total, 350 referred cases were analysed. A diagnosis of definite axial spondyloarthritis (axial SpA), comprising established AS and pre-radiographic axial SpA, could be made in 45.4% of all referred patients (of which 50.3% were classified as AS and 49.7% as preradiographic axial SpA), whereas 45.4% were classified as non-SpA and 9.1% as possible SpA. A diagnosis of definite axial SpA could be made in 34.2% if only one referral parameter was positive, and in 62.6% if there was >1 positive referral parameter. Conclusions: The proposed referral parameters have proven useful when applied in primary care in identifying patients with AS/pre-radiographic axial SpA among young to middle-aged patients with chronic low back pain.

Sexual abstinence only programmes to prevent HIV infection in high income countries: systematic review

Abstract: Objective To assess the effects of sexual abstinence only programmes for HIV prevention among participants in high income countries. Design Systematic review. Data sources 30 electronic databases without linguistic or geographical restrictions to February 2007, contacts with experts, hand searching, and cross referencing. Review methods Two reviewers independently applied inclusion criteria and extracted data, resolving disagreements by consensus and referral to a third reviewer. Randomised and quasirandomised controlled trials of abstinence only programmes in any high income country were included. Programmes aimed to prevent HIV only or both pregnancy and HIV. Trials evaluated biological outcomes (incidence of HIV, sexually transmitted infection, pregnancy) or behavioural outcomes (incidence or frequency of unprotected vaginal, anal, or oral sex; incidence or frequency of any vaginal, anal, or oral sex; number of partners; condom use; sexual initiation). Results The search identified 13 trials enrolling about 15 940 US youths. All outcomes were self reported. Compared with various controls, no programme affected incidence of unprotected vaginal sex, number of partners, condom use, or sexual initiation. One trial observed adverse effects at short term follow-up (sexually transmitted infections, frequency of sex) and long term follow-up (sexually transmitted infections, pregnancy) compared with usual care, but findings were offset by trials with non-significant results. Another trial observed a protective effect on incidence of vaginal sex compared with usual care, but this was limited to short term follow-up and countered by trials with non-significant findings. Heterogeneity prevented meta-analysis. Conclusion Programmes that exclusively encourage abstinence from sex do not seem to affect the risk of HIV infection in high income countries, as measured by self reported biological and behavioural outcomes.

Improving end-of-life care for patients with chronic heart failure: “Let’s hope it’ll get better, when I know in my heart of hearts it won’t”

Abstract: Objective Although chronic heart failure (CHF) has a high mortality rate and symptom burden, and clinical guidance stipulates palliative care intervention, there is a lack of evidence to guide clinical practice for patients approaching the end of life. This study aimed to formulate guidance and recommendations for improving end of life care in CHF. The objectives were to generate data on patients and carers? preferences regarding future treatment modalities, and to investigate communication between staff, patient and carer on end of life issues. Design Semi-structured qualitative interviews were conducted with 20 CHF patients (New York Heart Association functional classification III-IV); 11 family carers; 6 palliative care clinicians and 6 cardiology clinicians. Setting A tertiary hospital in London, UK. Results Patients and families reported a wide range of end of life care preferences. None had discussed these with their clinicians, and none were aware of choices or alternatives in future care modalities, such as adopting a palliative approach. Patients and carers live with fear and anxiety, and are uninformed about the implications of their diagnosis. Cardiac staff confirmed that they rarely raise such issues with patients. Disease specific and specialism-specific barriers to improving end of life care were identified. Conclusions This novel, integrated data provides three recommendations for improving care in line with policy directives: sensitive provision of information and discussion of end of life issues with patients and families; mutual education of cardiology and palliative care staff; and mutually agreed palliative care referral criteria and care pathways for CHF patients.

Management of obesity in primary care: nurses? practices, beliefs and attitudes

Abstract: Aim. This paper is a report of a study to investigate patterns of clinical practice, beliefs and attitudes of primary care nurses with respect to obesity management. Background. Nurses in primary care potentially play a key role in managing obesity, which has become a priority issue. There have been few studies of either the extent of clinical practice of nurses, or their attitudes and beliefs in this setting. Methods. A correlational survey design was employed. Structured questionnaires were posted to 564 nurses and health visitors in primary care organizations in England. The response rate was 72·3%. The survey was conducted in April and May 2006. Findings. Very few respondents reported training in obesity management, and most did not believe that organizational support was in place. Only practice nurses reported substantial clinical activity in obesity management, accounting for almost 5% of their contracted hours. This activity, comprised of assessment, lifestyle change support and referral, occurred in one-to-one consultations. Other nurses and health visitors reported much less activity, although they believed obesity to be an important health issue and its management an appropriate part of their role. Whilst outright negative stereotypes were rare, there were nevertheless a range of potentially negative beliefs and attitudes relating to obesity and obese patients. These views were related to the respondent's own body mass index but not to gender, age, experience and occupation. Conclusion. Training and organizational support for obesity management are required by primary care nurses. Training should also address beliefs and attitudes about obesity and obese persons.

Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia

Abstract: Problem In Cambodia, care for people with HIV/AIDS (prevalence 1.9%) is expanding, but care for people with type II diabetes (prevalence 5–10%), arterial hypertension and other treatable chronic diseases remains very limited. Approach We describe the experience and outcomes of offering integrated care for HIV/AIDS, diabetes and hypertension within the setting of chronic disease clinics. Local setting Chronic disease clinics were set up in the provincial referral hospitals of Siem Reap and Takeo, 2 provincial capitals in Cambodia. Relevant changes At 24 months of care, 87.7% of all HIV/AIDS patients were alive and in active follow–up. For diabetes patients, this proportion was 71%. Of the HIV/AIDS patients, 9.3% had died and 3% were lost to follow-up, while for diabetes this included 3 (0.1%) deaths and 28.9% lost to follow-up. Of all diabetes patients who stayed more than 3 months in the cohort, 90% were still in follow-up at 24 months. Lessons learned Over the first three years, the chronic disease clinics have demonstrated the feasibility of integrating care for HIV/AIDS with non-communicable chronic diseases in Cambodia. Adherence support strategies proved to be complementary, resulting in good outcomes. Services were well accepted by patients, and this has had a positive effect on HIV/AIDS-related stigma. This experience shows how care for HIV/AIDS patients can act as an impetus to tackle other common chronic diseases.

Who joins support groups among parents of children with autism

Abstract: This study identified factors associated with support group participation among families of children with autism. A survey was administered to 1005 caregivers of children with autism in Pennsylvania. Two-thirds of respondents (66.4%) had ever participated in an autism-specific support group. In adjusted analyses, demographic characteristics, including age and sex of the child, ethnicity and parental education and income, were associated with support group participation. Parents of children with self-injurious behavior, sleep problems or severe language deficits were more likely to belong, as were parents whose diagnosing clinician referred them to a support group. The results of this study suggest the importance of clinician referrals to groups, and the need to make groups available to under-served populations.

Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors.

Abstract: This study examines the Chronic Care Model (CCM) as a framework for preventing health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity. Data were obtained from primary care practices participating in a national health promotion initiative sponsored by the Robert Wood Johnson Foundation. Practices owned by a hospital health system and exhibiting a culture of quality improvement were more likely to offer recommended services such as health risk assessment, behavioral counseling, and referral to community-based programs. Practices that had a multispecialty physician staff and staff dieticians, decision support in the form of point-of-care reminders and clinical staff meetings, and clinical information systems such as electronic medical records were also more likely to offer recommended services. Adaptation of the CCM for preventive purposes may offer a useful framework for addressing important health risk behaviors.

Offering Integrated Care for HIV/AIDS, Diabetes and Hypertension within Chronic Disease Clinics in Cambodia/Offre De Soins Integree a L'intention Des Personnes Vivant Avec le VIH/sida, Un Diabete Ou De L'hypertension Par Les Dispensaires Cambodgiens Specialises Dans Les Maladies Chroniques/ Atencion Integrada Contra El VIH/SIDA, la Diabetes Y la Hipertension En Dispensarios De Enfermedades Cronicas De Camboya

Abstract: Introduction At the end of 2004, there were an estimated 100 000 people living with HIV/ AIDS in Cambodia, of whom approximately 25 000 were estimated to urgently require care and treatment with highly active antiretroviral therapy (HAART). (1,2) Cambodia is struggling with a growing burden of chronic diseases. A survey done in 2005 estimated that between 5% and 11% of all adults had type II diabetes and the prevalence of impaired glucose intolerance was between 10% and 15%. The same survey showed that between 12% and 25% of the population screened could be classified as being hypertensive. (3) These results are consistent with growing evidence that diabetes and other non-communicable diseases represent a significant and growing part of the disease burden in low-income countries. (4,5) In 2002, Medecins Sans Frontieres (MSF) and the Cambodian Ministry of Health established chronic disease clinics to integrate HIV/AIDS care with the management of diabetes and hypertension in two provincial capitals, Takeo and Siem Reap. This paper describes the approach and outcomes of this strategy. Context Siem Reap and Takeo are both predominantly rural provinces, although the urban population of Siem Reap town is increasing rapidly due to growing tourism around the Angkor Wat temple complex. Both locations were selected for this pilot programme because they are large provincial centres with referral hospital capacity to expand activities. Furthermore, adequate care for the target diseases at these sites was lacking. HAART began to be provided in Cambodia in 2001. By the end of 2005, 12 355 people were on treatment through programmes run jointly by the Ministry of Health and nongovernmental organizations (NGOs). Chronic diseases are largely neglected in developing countries. (6) In Cambodia, medical care for diseases such as diabetes, arterial hypertension and epilepsy was not generally included in the reconstruction of the health care system over the past 15 years. Most diabetics receive only limited medication at referral hospital outpatient departments or when they arrive with severe hyperglycaemia at emergency wards; they are rarely referred to long-term care once they are discharged. Some drugs to treat arterial hypertension are available at hospitals and health centres, but these are usually provided for only two weeks. Rationale for the chronic disease clinics The rationale to combine care of HIV/ AIDS, diabetes and hypertension was based on three assumptions. First, the availability of antiretroviral treatment in developing countries is transforming HIV/AIDS into a chronic disease, as has been the experience elsewhere. (7) It was anticipated that in this resource-poor context, efficiency gains could be attained through the establishment of a multidisciplinary chronic disease care team that would use a common approach to respond to the needs of chronic disease patients, especially in providing continuity of care, long-term adherence support and social support. Second, in Cambodian society as elsewhere, the stigma attached to HIV/ AIDS presents a barrier to care. By providing care for seropositive clients and patients with other chronic diseases within the same facility, it was hoped that facility-related stigma could be reduced. Third, it was considered important that the care delivery model should reflect epidemiological realities. Although at the clinics' inception reliable epidemiological data on diabetes and other chronic diseases was lacking, these illnesses were recognized to contribute an increasing share of the total burden of disease in Cambodia. Diabetes was given a specific priority, since it was seen by many health workers as a frequent problem. The provision of systematic and continuous care for chronic diseases was encouraged by both the Ministry of Health and local WHO representatives, who were involved in the final design of this pilot health care delivery model. …

Improving the quality of care for mild to moderate dementia: an evaluation of the Croydon Memory Service Model.

Abstract: Background: The large majority of people with dementia receive nothing in the way of specialist assessment and care at any stage of their illness. There is a particular lack of services focussed on early identification and intervention in dementia where there is the possibility of long-term harm reduction for people with dementia and their family carers. We have developed a model of care that is complementary to local systems of health and social care (The Croydon Memory Service Model [CMSM]). This is a low-cost, high-throughput, generic service to enable early identification and intervention in dementia. It is a multi-agency approach with joint ownership by health services, social services and the voluntary sector with embedded specifically-tailored approaches to primary care and minority ethnic communities. Method: We completed a service evaluation of the introduction of the CMSM in a single borough in South London. Six predefined service goals were set: high acceptability; high appropriate referral rate; successful engagement with people from minority ethnic groups; successful engagement with people with young onset dementia; focus on engagement with mild cases to enable early intervention; and an increase in the overall number of new cases of dementia seen. Mixed qualitative and quantitative methodologies were used including a description and 6-month follow-up of a cohort of 290 consecutive referrals. Results: All key predefined service goals were met: 95% acceptability; 94% appropriate referrals; successful engagement with minority ethnic groups (two-fold greater number compared with that expected from general population demographic data); 17% of referrals under 65 years of age; 68% referrals with mild or minimal dementia severity; and an estimated 63% increase in the number of new cases of dementia seen in Croydon. At 6-month follow up, those referred to the service had decreased behavioural disturbance and increased quality of life compared with baseline. Conclusions: Specific services for early dementia, which deliver diagnosis and care, can be established. These services can increase the numbers of people with early dementia identified and provided with care. Those receiving such services appear to improve in terms of quality of life and behavioural and psychological symptoms of dementia. Next steps should include the establishment of such services in other representative areas and evaluation of their effectiveness in comparison with other models of care.

Prevalence of communication disorders compared with other learning needs in 14 500 primary and secondary school students

Abstract: Background: Prevalence data are of interest to health professionals and educators to assist in the planning of service delivery, allow for the calculation of the level of impact of intervention, and allow for the consideration of the boundaries between typical development and impairment.Aims: To determine the prevalence of children with communication disorders and other learning needs as identified by their teachers within all primary and secondary schools in an Australian school district over a 3‐year period.Methods & Procedures: Children with learning needs were identified from 14 514 students in the first year (wave 1) and the 14 533 students 2 years later (wave 2). Children were identified via a four‐phased data‐collection process designed to reduce selection and misclassification bias. Identification included teacher training, teacher referral, confirmation by documentation from relevant professionals including speech and language therapists, audiologists, psychologists and doctors, and verification ...

Early rheumatoid arthritis -- is there a window of opportunity?

Abstract: The early diagnosis and treatment of nascent rheumatoid arthritis (RA) has become a prime objective for rheumatologists and clinicians who care for patients with arthritis. Population-based studies have consistently shown that patients with RA are at substantial risk for progressive joint damage, disability, and increased morbidity and mortality. These inevitable outcomes are closely linked to the consequences of rheumatoid inflammation, which begins early and is progressive in all. At issue is whether early diagnosis, coupled with aggressive therapy, might alter the natural history of this RA. If this "window of opportunity" exists, then outcomes should be substantially altered by delivering the right therapies at the right time. A growing body of evidence has emphasized the consistent clinical and radiographic benefits of early, aggressive treatment of RA. These studies confirm that all therapies - monotherapy, combination disease modifying antirheumatic drugs (DMARD), biologics - work better in early disease than in long-established RA. Earlier identification, referral, and an accurate diagnosis of RA can now be rewarded with highly effective DMARD or biologic therapies. Rheumatologists should rise to the challenge and educate clinicians about this window of opportunity, the potential for remission, and superior clinical responses when patients with early RA or undifferentiated arthritis are referred to and managed by experts in aggressive rheumatologic care.

Adherence to Antidepressant Treatment Among Privately Insured Patients Diagnosed With Depression

Abstract: Depression imposes a substantial burden at the population level, with a lifetime prevalence of 13–16%, significant associated disability, and a liability to relapse.1–4 Its negative outcomes include suicide, substantial impairment, lower quality of life, increased health care utilization and cost, and adverse impact on employment productivity.3–10 Antidepressant treatment is efficacious, and treatment adherence is important in achieving effectiveness, ie, remission, restoring previous level of functioning, and preventing reoccurrence.11–13 Specifically, antidepressants are recommended to be continued for at least 4 months beyond the initial symptom resolution.14 Early discontinuation of antidepressant treatment has been documented in various populations and clinical settings.15–22 Existing findings on correlates/predictors of adherence to antidepressants often focus on a limited range of sociodemographic and clinical characteristics and have sometimes produced inconsistent findings. Comorbid medical conditions generally are associated with poor adherence,20 but findings on age and gender variations are mixed.15,20–23 Use of newer drugs20–22,24 and mental health specialty services15,16,20,21,25 generally have been associated with better antidepressant adherence. Economic status has rarely been included as an explanatory variable; we identified 1 study, which reported a positive association between income and adherence among veterans.15 Effects of economic-status variables on adherence have more often been studied with other pharmaceutical treatments, but the results are inconsistent.26 There is a need for up-to-date data because pronounced secular trends have been documented in depression care.27 Depression care improvement can be approached as a special case of the broader effort to improve management of chronic conditions of all kinds. The most prominent model, the chronic care model of Wagner and colleagues,28 frames clinical issues as multilevel challenges, and has motivated several initiatives to improve depression care.29–33 The Depression in Primary Care program, for example, identifies barriers and intervention opportunities at 6 levels (patient/consumer, provider, practice/delivery systems, plans, purchasers (public/private), and populations/policies).34 In this study, we investigated factors associated with poor adherence in a privately insured population using medical and pharmacy claims. Our goal was to examine the impact of patient characteristics in the context of provider, practice/delivery systems, or plan level variables, with the implications for policy and service system interventions likely to be of interest to purchasers and other stakeholders. Available variables include patients' demographic/economic characteristics, comorbid alcohol and other substance abuse, other prevalent comorbid conditions, depression treatment patterns, general use of health and pharmacy services, and insurance plan type. We conceptualized these variables based on their potential for modification by intervention at one or another level. For example, although patient behavior can be modified (eg, by education), most patient level variables available in our data are nonmodifiable (eg, demographics). Comorbid substance abuse is open to direct modification by treatment and to indirect influence by provider and practice innovations (eg, screening, prevention). Possibly open to some influence from higher level organizational interventions are the care sector of the initial depression diagnosis or use patterns of general medical services and pharmacy. Variables potentially open to organizational level interventions are follow-up care from mental health specialists, medication class, and company policies (eg, gate-keeping/authorization/referral requirements, financial incentives/costs etc.). We use plan type as a proxy for policies.