Showing papers on "Referral published in 2010"

Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice

Abstract: year, more than 400 000 infants are born to mothers who are depressed, which makes perinatal depression the most underdiag- nosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Pediatric practices, as medical homes, can establish a system to implement postpartum depression screening and to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child (dyad) relationship. This system would have a positive effect on the health and well-being of the infant and family. State chapters of the American Academy of Pediatrics, working with state Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and maternal and child health programs, can increase awareness of the need for perinatal depression screening in the obstetric and pedi- atric periodicity of care schedules and ensure payment. Pediatricians must advocate for workforce development for professionals who care for very young children and for promotion of evidence-based interven- tions focused on healthy attachment and parent-child relationships. Pediatrics 2010;126:1032-1039 BACKGROUND Maternal and paternal depression affect the whole family. 1 This report will specifically focus on the impact of maternal depression on the young infant and the role of the primary care clinician in recognizing perinatal depression. Perinatal depression is a major/minor depres- sive disorder with an episode occurring during pregnancy or within the first year after birth of a child. A family history of depression, alcohol abuse, and a personal history of depression increase the risk of perinatal depression. 2 The incidence of perinatal depression varies with the population sur- veyed, but estimated rates for depression among pregnant and post- partum women have ranged from 5% to 25%. Studies of low-income mothers and pregnant and parenting teenagers have reported rates of depressive symptoms at 40% to 60%. In general, as many as 12% of all pregnant or postpartum women experience depression in a given year, and for low-income women, the prevalence is doubled.1 The rate of major and minor depression varies during pregnancy from 8.5% to 11.0%, and in the first year after birth of a child, the rate ranges from

Distress management: Clinical practice guidelines in Oncology™

Abstract: The integration of psychosocial care into the routine care of all patients with cancer is increasingly being recognized as the new standard of care. These NCCN Clinical Practice Guidelines in Oncology for Distress Management discuss the identifica tion and treatment of psychosocial problems in patients with cancer. They are intended to assist oncology teams identify patients who require referral to psychosocial resources and to give oncology teams guidance on interventions for patients with mild distress to ensure that all patients with distress are recognized and treated. (JNCCN 2013;11:190–209)

A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evaluation (PCARE) Study

Abstract: Objective: Poor quality of healthcare contributes to impaired health and excess mortality in individuals with severe mental disorders. The authors tested a population-based medical care management intervention designed to improve primary medical care in community mental health settings. Method: A total of 407 subjects with severe mental illness at an urban community mental health center were randomly assigned to either the medical care management intervention or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education, and support in overcoming system-level fragmentation and barriers to primary medical care. Results: At a 12-month follow-up evaluation, the intervention group received an average of 58.7% of recommended preventive services compared with a rate of 21.8% in the usual care group. They also received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% versus 27.7%) and were more likely to have a primary care provider (71.2% versus 51.9%). The intervention group showed significant improvement on the SF-36 mental component summary (8.0% [versus a 1.1% decline in the usual care group]) and a nonsignificant improvement on the SF36 physical component summary. Among subjects with available laboratory data, scores on the Framingham Cardiovascular Risk Index were significantly better in the intervention group (6.9%) than the usual care group (9.8%). Conclusions: M edical care management was associated with significant improve ments in the quality and outcomes of primary care. These findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.

Population-based risk factors and resource utilization for HCC: US perspective.

Abstract: Objective:Hepatocellular carcinoma (HCC) is a deadly cancer with limited treatment options. HCC cases in the United States (US) were identified from a claims database to analyze the risk factors, the health care provider referral patterns, and treatment options in actual (real-world) clinical settings.Methods:MarketScan, a health care claims database from Thomas Reuters covering 18 million lives yearly and all US census regions from 2002 to 2008, was used to identify HCC patients and obtain data on patient characteristics, health care providers, and treatment utilization (i.e., medications, interventions).Results:HCC cases (n = 4406) were identified with an annual incidence of 0.4 per 1000 covered lives (i.e., those currently enrolled in a health care plan) from 2002 to 2008. Nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH) was the most common underlying etiologic risk factor (59%), followed by diabetes (36%) and hepatitis C virus infection (22%). Primary care/internal ...

The effect of age and gender on bladder cancer: a critical review of the literature.

Abstract: While patient age and gender are important factors in the clinical decision-making for treating urothelial carcinoma of the bladder (UCB), there are no evidence-based recommendations to guide healthcare professionals. We review previous reports on the influence of age and gender on the incidence, biology, mortality and treatment of UCB. Using MEDLINE, we searched for previous reports published between January 1966 and July 2009. While men are three to four times more likely to develop UCB than women, women present with more advanced disease and have worse survival rates. The disparity among genders is proposed to be the result of a differential exposure to carcinogens (i.e. tobacco and chemicals) as well as reflecting genetic, anatomical, hormonal, societal and environmental factors. Inpatient length of stay, referral patterns for haematuria and surgical outcomes suggest that inferior quality of care for women might be an additional cause of gender inequalities. Age is the greatest single risk factor for developing UCB and dying from it once diagnosed. Elderly patients face both clinical and institutional barriers to appropriate treatment; they receive less aggressive treatment and sub-therapeutic dosing. Much evidence suggests that chronological age alone is an inadequate indicator in determining the clinical and behavioural response of older patients to UCB and its treatment. Epidemiological and mechanistic molecular studies should be encouraged to design, analyse and report gender- and age-specific associations. Improved bladder cancer awareness in the lay and medical communities, careful patient selection, treatment tailored to the needs and the physiological and physical reserve of the individual patient, and proactive postoperative care are particularly important. We must strive to develop transdisciplinary collaborative efforts to provide tailored gender- and age-specific care for patients with UCB.

Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study

Abstract: Objective To evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records. Design Mixed-method, multilevel case study. Setting English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts. Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively. Results Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme’s fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort. Conclusions Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.

Detection, treatment, and referral of perinatal depression and anxiety by obstetrical providers.

Abstract: Aims: This study aimed to assess the rates of detection, treatment, and referral of maternal depression and anxiety by obstetrical providers during pregnancy and at 6 weeks postpartum. Methods: A convenience sample of women receiving obstetrical care at a large urban teaching hospital (n = 491) was screened for depression and anxiety during the third trimester of pregnancy and again at 6 weeks postpartum using the Edinburgh Postnatal Depression Scale and the anxiety portions of the Patient Health Questionnaire. Participants were also asked if they thought they needed help for depression, anxiety, or stress at the two time points. Obstetrical providers were blind to screening results. Two months postdelivery, each woman's obstetrical electronic medical record (EMR) was reviewed for documentation of psychiatric symptoms, diagnoses, psychiatric treatment, and mental health referrals at the two time points. Data were analyzed using descriptive statistics. Results: Twenty-three percent of participants...

Determinants of male involvement in the prevention of mother-to-child transmission of HIV programme in Eastern Uganda: a cross-sectional survey

Abstract: Mother-to-child transmission of HIV (MTCT) accounts for over 95% of all paediatric HIV infections worldwide. Several studies have shown that male participation in the antenatal care of their spouses together with couple counselling and testing for HIV, increases use of the interventions for HIV prevention. The prevention programme of MTCT (PMTCT) was launched in Uganda in 2000 and Mbale in 2002. Less than 10% of the pregnant women accepted antenatal HIV testing at Mbale Regional Referral Hospital in 2003; couple counselling and testing for HIV was low. Therefore, we conducted the study to determine the level of male involvement and identify its determinants in the PMTCT programme. A cross-sectional survey of 388 men aged 18 years or more, whose spouses were attending antenatal care at Mbale Regional Referral Hospital, was conducted in Mbale district, Eastern Uganda. A male involvement index was constructed based on 6 questions. The survey was complemented by eight focus group discussions and five in-depth interviews. The respondents had a median age of 32 years (inter-quartile range, IQR: 28-37). The majority (74%) had a low male involvement index and only 5% of men accompanied their spouses to the antenatal clinic. Men who had attained secondary education were more likely to have a high male involvement index (OR: 1.9, 95% CI: 1.1-3.3) than those who had primary or no formal education. The respondents, whose occupation was driver (OR: 0.3, 95% CI: 0.1-0.7) or those who had fear of disclosure of their HIV sero-status results to their spouses (OR: 0.4, 95% CI: 0.2-0.8), were less likely to have a high male involvement index. Barriers to male involvement in the PMTCT programme were related to both the poor health system, to socio-economic factors and to cultural beliefs. Structural and cultural barriers to men's involvement in the PMTCT programme in Mbale district were complex and interrelated. Community sensitization of men about the benefits of antenatal care and PMTCT and improving client-friendliness in the clinics needs to be prioritised in order to improve low male participation and mitigate the effect of socio-economic and cultural factors.

Making decisions for people with dementia who lack capacity: qualitative study of family carers in UK.

Abstract: Objective: To identify common difficult decisions made by family carers on behalf of people with dementia, and facilitators of and barriers to such decisions, in order to produce information for family carers about overcoming barriers. / Design: Qualitative study to delineate decision areas through focus groups and complexity of decision making in individual interviews. / Setting: Community settings in London. / Participants: 43 family carers of people with dementia in focus groups and 46 carers who had already made such decisions in individual interviews. / Results: Family carers identified five core problematic areas of decision making: accessing dementia related health and social services; care homes; legal-financial matters; non-dementia related health care; and making plans for the person with dementia if the carer became too ill to care for them. They highlighted the difficulties in making proxy decisions, especially against active resistance, and their altered role of patient manager while still a family member. Families devised strategies to gain agreement in order to ensure that the person with dementia retained dignity. / Conclusions: The following strategies helped with implementation of decisions: introducing change slowly; organising legal changes for the carer as well as the patient; involving a professional to persuade the patient to accept services; and emphasising that services optimised, not impeded, independence. To access services, carers made patients’ general practice appointments, accompanied them to the surgery, pointed out symptoms, gained permission to receive confidential information, asked for referral to specialist services, and used professionals’ authority to gain patients’ agreement. End of life decisions were particularly difficult. They were helped by knowledge of the person with dementia’s previous views, clear prognostic information, and family support. Information sheets to help carers to overcome barriers to proxy decision making have been developed; their impact in practice has yet to be evaluated.

Referral pattern for epilepsy surgery after evidence-based recommendations A retrospective study

Abstract: Background: Class I evidence for surgical effectiveness in refractory temporal lobe epilepsy (TLE) in 2001 led to an American Academy of Neurology practice parameter in 2003 recommending “referral to a surgical epilepsy center on failing appropriate trials of first-line antiepileptic drugs.” We examined whether this led to a change in referral patterns to our epilepsy center. Methods: We compared referral data for patients with TLE at our center for 1995 to 1998 (group 1, n = 83) and 2005 to 2008 (group 2, n = 102) to determine whether these recommendations resulted in a change in referral patterns for surgical evaluation. Patients with brain tumors, previous epilepsy surgery evaluations, or brain surgery (including epilepsy surgery) were excluded. Results: We did not find a difference between the groups in the duration from the diagnosis of habitual seizures to referral (17.1 ± 10.0 vs 18.6 ± 12.6 years, p = 0.39) or the age at the time of evaluation (34.1 ± 10.3 vs 37.0 ± 11.8 years, p = 0.08). However, there was a difference in the distributions of age at evaluation ( p = 0.03) and the duration of pharmacotherapy ( p = 0.03) between the groups, with a greater proportion of patients in group 2 with drug-resistant epilepsy both earlier and later in their treatment course. Nonepileptic seizures were referred significantly earlier than TLE in either group or when combined. Conclusions: Our analysis does not identify a significantly earlier referral for epilepsy surgery evaluation as recommended in the practice parameter, but suggests a hopeful trend in this direction.

Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis.

Abstract: Background Chronic kidney disease (CKD) is a long-term condition and has been described as the gradual loss of kidney function over time. Early in the disease process, people with CKD often experience no symptoms. For a long time, CKD has been an underdiagnosed condition. Even in the absence of symptoms, CKD appears to add significantly to the burden of cardiovascular disease and death and, for an important minority, can progress to kidney failure. Objective To systematically review the evidence of the clinical effectiveness and cost-effectiveness of early referral strategies for management of people with markers of renal disease. Data sources Electronic searches of 12 major databases (such as MEDLINE, EMBASE, CINAHL, etc.) were conducted for the time period of 1990 to April 2008 to identify studies comparing early referral to other care options for people with CKD. Additional searching was performed in the NHS Economic Evaluation Database to support the cost-effectiveness literature review. Review methods Two authors reviewed all titles, abstracts and full papers to select relevant literature. A Markov model was constructed to represent the natural history of CKD. The model allowed cohorts to be tracked according to estimated glomerular filtration rate (eGFR) status and the presence of other complications known to influence CKD progression and the incidence of cardiovascular events. Results From 36 relevant natural history studies, CKD was found to be, despite marked heterogeneity between studies, a marker of increased risk of mortality, renal progression and end-stage renal disease. Mortality was generally high and increased with stage of CKD. After adjustment for comorbidities, the relative risk of mortality among those with CKD identified from the general population increased with stage. For clinical populations, the relative risk was higher. All three outcomes increased as eGFR fell. Only seven studies, and no randomised controlled trials, were identified as relevant to assessing the clinical effectiveness of early referral strategies for CKD. In the five retrospective studies constructed from cohorts starting on renal replacement therapy (RRT), mortality was reduced in the early referral group (more than 12 months prior to RRT) even as late as 5 years after initiation of RRT. Only two studies included predialysis participants. One study, in people screened for diabetic nephropathy, reported a reduction in the decline in renal function associated with early referral to nephrology specialists (eGFR decline 3.4 ml/min/1.73 m(2)) when compared with a similar group that had no access to nephrology services until dialysis was required (eGFR decline 12.0 ml/min/1.73 m(2)). The second study, among a group of veterans with two creatinine levels of at least 140 mg/dl, reported that a composite end point of death or progression was lower in the group receiving nephrology follow-up than in those receiving only primary care follow-up. The greatest effect was observed in those with stage 3 or worse disease after adjustment for comorbidities, age, race, smoking and proteinuria {stage 3: hazard ratio (HR) 0.8 [95% confidence interval (CI) 0.61 to 0.9)]; stage 4: HR 0.75 (95% CI 0.45 to 0.89)}. In the base-case analysis, all early referral strategies produced more quality-adjusted life-years (QALYs) than referral upon transit to stage 5 CKD (eGFR 15 ml/min/1.73 m(2)). Referral for everyone with an eGFR below 60 ml/min/1.73 m(2) (stage 3a CKD) generated the most QALYs and, compared with referral for stage 4 CKD (eGFR < 30 ml/min/1.73 m(2)), had an incremental cost-effectiveness ratio of approximately 3806 pounds per QALY. Limitations Because of a lack of data on the natural history of CKD in individuals without diabetes, and a lack of evidence on the costs and effects of early referral, the Markov model relied on many assumptions. The findings were particularly sensitive to changes in eGFR decline rates and the relative effect of early referral on CKD progression and cardiovascular events; the latter parameter being derived from a single non-randomised study. Conclusions Despite substantial focus on the early identification and proactive management of CKD in the last few years, we have identified significant evidence gaps about how best to manage people with CKD. There was some evidence to suggest that the care of people with CKD could be improved and, because these people are at risk from both renal and cardiovascular outcomes, strategies to improve the management of people with CKD have the potential to offer an efficient use of health service resources. Given the number of people now being recognised as having markers of kidney impairment, there is an urgent need for further research to support service change.

Principles of the Patient-Centered Medical Home and Preventive Services Delivery

Abstract: PURPOSE Limited research exists examining the principles of the patient-centered medical home (PCMH) and improved outcomes. We examined whether PCMH principles (personal physician, physician-directed team, whole-person orientation, coordination of care, quality and safety, and enhanced access) are associated with receipt of preventive services. METHODS We undertook cross-sectional analyses using baseline patient and practice member surveys and chart audits from a quality improvement trial in 24 primary care offices. Association of PCMH principles with preventive services (receipt of cancer screening, lipid screening, influenza vaccination, and behavioral counseling) was examined using hierarchical linear modeling. RESULTS Higher global PCMH scores were associated with receipt of preventive services (β=2.3; P <.001). Positive associations were found with principles of personal physician (β=3.7; P <.001), in particular, continuity with the same physician (β=4.4; P = .002) and number of visits within 2 years (15% higher for patients with 13 or more visits; P <.001); and whole-person orientation (β=5.6; P <.001), particularly, having a well-visit within 5 years (β=12.3; P <.001) and being treated for chronic diseases (6% higher if more than 3 chronic diseases; P = .002). Having referral systems to link patients to community programs for preventive counseling (β = 8.0; P <.001) and use of clinical decision-support tools (β = 5.0; P = .04) were also associated with receipt of preventive services. CONCLUSIONS Relationship-centered aspects of PCMH are more highly correlated with preventive services delivery in community primary care practices than are information technology capabilities. Demonstration projects and tools that measure PCMH principles should have greater emphasis on these key primary care attributes.

AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services: A Report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures

Abstract: Over the past decade, there has been an increasing awareness that the quality of medical care delivered in the United States is variable. In its seminal document dedicated to characterizing deficiencies in delivering effective, timely, safe, equitable, efficient, and patient-centered medical care, the Institute of Medicine described a quality “chasm”.1 Recognition of the magnitude of the gap between the care that is delivered and the care that ought to be provided has stimulated interest in the development of measures of quality of care and the use of such measures for the purposes of quality improvement and accountability. Consistent with this national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role in developing measures of the quality of care for cardiovascular disease (CVD) in several clinical areas Table 1. The ACCF/AHA Task Force on Performance Measures was formed in February 2000 and was charged with identifying the clinical topics appropriate for the development of performance measures and assembling writing committees composed of clinical and methodological experts. When appropriate, these committees include representatives from other organizations with an interest in the clinical topic under consideration. The committees are informed about the methodology of performance measure development and are instructed to construct measures for use both prospectively and retrospectively, rely upon easily documented clinical criteria, and where appropriate, incorporate administrative data. The data elements required for the performance measures are linked to existing ACCF/AHA clinical data standards to encourage uniform measurements of …

Patterns in Office Referral Data by Grade, Race/Ethnicity, and Gender.

Abstract: Research supports that office referral data is useful in informing programmatic decisions and in planning interventions such as Positive Behavior Interventions and Supports (PBIS). Knowledge of the different patterns of office referrals may facilitate the development of interventions that are targeted to specific groups of students. This study examines patterns in office referrals within an urban district by gender, race/ethnicity and grade. Findings reveal that there are clear differences by grade that appear to be related to developmental level, with greater numbers of referrals for aggression in younger students (grades K-8), greater numbers of referrals for disrespectful behavior in middle school students (grades 7-8), and greater numbers of referrals for attendance problems in high school students. There were also gender differences in the rate and type of referrals, with significantly more referrals for boys' delinquent and aggressive behavior than girls, which may relate to how schools define unacceptable behavior and the method used to collect this data. Finally, there were differences by race/ethnicity, in that there were significantly more referrals for African American/black students than Hispanic students, which suggest that schools need to consider students' racial/ethnic background in the development of behavioral expectations.

Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project

Abstract: BACKGROUND: Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance. METHODS: Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35 335 encounters. PCC surveys assessed satisfaction and impact on access to care. RESULTS: The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10 114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0–245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs. CONCLUSIONS: PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.

Is early diagnosis of oral cancer a feasible objective? Who is to blame for diagnostic delay?

Abstract: Worldwide, oral cancer has one of the lowest survival rates and poor prognosis remains unaffected despite recent therapeutic advances. Reducing diagnostic delay to achieve earlier detection is a cornerstone to improve survival. Thus, intervention strategies to minimize diagnostic delays resulting from patient factors and to identify groups at risk in different geographical areas seem to be necessary. The identification of a 'scheduling delay' in oral cancer justifies the introduction of additional educational interventions aimed at the whole health care team at dental and medical practices. The access to and the kind of healthcare system in a particular country are also relevant in this context, particularly the referral system. The design of a simple, clear, fail-safe, fast-track referral scheme for those suspected with cancer may diminish greatly the length of the delay. Moreover, there is a need for future investigations, which are methodologically adequate, that consider cultural and geographical aspects and use patient survival as the final outcome, that are able to recognize the agents/factors responsible for diagnostic delay by patients as well as healthcare providers and those attributable to the healthcare systems.

Impact of Patient Language Proficiency and Interpreter Service Use on the Quality of Psychiatric Care: A Systematic Review

Abstract: Objective This literature review examined the effects of patients' limited English proficiency and use of professional and ad hoc interpreters on the quality of psychiatric care. Methods PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were systematically searched for English-language publications from inception of each database to April 2009. Reference lists were reviewed, and expert sources were consulted. Among the 321 articles identified, 26 met inclusion criteria: peer-reviewed articles reporting primary data on clinical care for psychiatric disorders among patients with limited proficiency in English or in the provider's language. Results Evaluation in a patient's nonprimary language can lead to incomplete or distorted mental status assessment. Although both untrained and trained interpreters may make errors, untrained interpreters' errors may have greater clinical impact, compromising diagnostic accuracy and clinicians' detection of disordered thought or delusional content. Use of professional interpreters may improve disclosure in patient-provider communications, referral to specialty care, and patient satisfaction. Conclusions Little systematic research has addressed the impact of language proficiency or interpreter use on the quality of psychiatric care in contemporary U.S. settings. Findings are insufficient to inform evidence-based guidelines for improving quality of care among patients with limited English proficiency. Clinicians should be aware of the ways in which quality of care can be compromised when they evaluate patients in a nonprimary language or use an interpreter. Given U.S. demographic trends, future research should help guide practice and policy by addressing deficits in the evidence base.

The pathways to mental health care of first-episode psychosis patients: a systematic review.

Abstract: BackgroundAlthough there is agreement on the association between delay in treatment of psychosis and outcome, less is known regarding the pathways to care of patients suffering from a first psychotic episode. Pathways are complex, involve a diverse range of contacts, and are likely to influence delay in treatment. We conducted a systematic review on the nature and determinants of the pathway to care of patients experiencing a first psychotic episode.MethodWe searched four databases (Medline, HealthStar, EMBASE, PsycINFO) to identify articles published between 1985 and 2009. We manually searched reference lists and relevant journals and used forward citation searching to identify additional articles. Studies were included if they used an observational design to assess the pathways to care of patients with first-episode psychosis (FEP).ResultsIncluded studies (n=30) explored the first contact in the pathway and/or the referral source that led to treatment. In 13 of 21 studies, the first contact for the largest proportion of patients was a physician. However, in nine of 22 studies, the referral source for the greatest proportion of patients was emergency services. We did not find consistent results across the studies that explored the sex, socio-economic, and/or ethnic determinants of the pathway, or the impact of the pathway to care on treatment delay.ConclusionsAdditional research is needed to understand the help-seeking behavior of patients experiencing a first-episode of psychosis, service response to such contacts, and the determinants of the pathways to mental health care, to inform the provision of mental health services.

Enhancing dementia care: a primary care-based memory clinic.

Abstract: Memory clinics have been promoted as opportunities for improving dementia diagnosis and care. This article describes the implementation of an interdisciplinary memory clinic within primary care in Ontario, Canada, that aims to provide timely access to comprehensive assessment and care and to improve referring physicians' knowledge of the management of dementia through collaborative care and practice-based mentorship. Between July 2006 and September 2009, 246 initial and follow-up assessments were conducted with 151 patients, a high proportion of whom received a new diagnosis of mild cognitive impairment (44.4%) or dementia (19.2%). A trial of cholinesterase inhibitors was recommended for almost all patients newly diagnosed with dementia. Management interventions and recommendations included social worker outreach, long-term care planning, home safety or driving assessments, referral to community resources, and periodic follow-up and monitoring. A small proportion of patients (7.8%) were referred to a specialist. Surveyed patients and caregivers were very satisfied with their visit to the clinic. A chart audit conducted by two independent geriatricians indicated agreement with diagnosis and intervention, particularly related to use of specialists. The results indicate that memory clinics within primary care settings can support capacity building to ensure quality assessment and management of dementia at a primary care level.

Effects of cardiac rehabilitation referral strategies on referral and enrollment rates

Abstract: Despite recommendations in clinical practice guidelines, evidence suggests that utilization of cardiac rehabilitation (CR) following indicated cardiac events is low Referral strategies, such as automatic referral, have been advocated to improve CR utilization In this Review, we evaluate the effects of referral strategies on rates of CR referral and enrollment Referral strategies are categorized as 'automatic' (the use of electronic health records or systematic discharge order sets), as 'liaison' (discussions with allied health-care providers), or as 'other' (for example, the use of motivational letter to patients) The highest rates of CR referral have been achieved in studies implementing automatic referral orders, whereas the highest rates of CR enrollment have resulted from a combination of automatic and liaison methods Overall, innovative referral strategies significantly increase CR utilization While further investigation is needed, institutions should evaluate their CR referral practice in light of these findings

Outreach and screening following the 2005 London bombings: usage and outcomes

Abstract: BACKGROUND: Little is known about how to remedy the unmet mental health needs associated with major terrorist attacks, or what outcomes are achievable with evidence-based treatment. This article reports the usage, diagnoses and outcomes associated with the 2-year Trauma Response Programme (TRP) for those affected by the 2005 London bombings. Method: Following a systematic and coordinated programme of outreach, the contact details of 910 people were obtained by the TRP. Of these, 596 completed a screening instrument that included the Trauma Screening Questionnaire (TSQ) and items assessing other negative responses. Those scoring 6 on the TSQ, or endorsing other negative responses, received a detailed clinical assessment. Individuals judged to need treatment (n=217) received trauma-focused cognitive-behaviour therapy (TF-CBT) or eye movement desensitization and reprocessing (EMDR). Symptom levels were assessed pre- and post-treatment with validated self-report measures of post-traumatic stress disorder (PTSD) and depression, and 66 were followed up at 1 year. RESULTS: Case finding relied primarily on outreach rather than standard referral pathways such as primary care. The effect sizes achieved for treatment of DSM-IV PTSD exceeded those usually found in randomized controlled trials (RCTs) and gains were well maintained an average of 1 year later. CONCLUSIONS: Outreach with screening, linked to the provision of evidence-based treatment, seems to be a viable method of identifying and meeting mental health needs following a terrorist attack. Given the failure of normal care pathways, it is a potentially important approach that merits further evaluation. Language: en

Nutrition in primary care: current practices, attitudes, and barriers.

Abstract: OBJECTIVE To investigate what role family physicians currently play in the management of patients with nutrition-related issues and whether implementation of current nutrition counseling guidelines is feasible in primary care practices. DESIGN Mailed survey. SETTING Family practice offices in British Columbia. PARTICIPANTS A total of 451 Canadian-trained family physicians practising in British Columbia. MAIN OUTCOME MEASURES Respondents’ demographic characteristics; respondents’ attitudes about and perceived barriers to nutrition counseling, as well as their current practices and training in this area. RESULTS Among the 757 physicians surveyed, the response rate was 59.6%. Overall, respondents had positive attitudes about the role of nutrition in patient health, and most physicians (58.1%) believed that more than 60% of their patients would benefit from nutrition counseling. However, there was a considerable gap between the proportion of patients who respondents thought would benefit from nutrition counseling and the proportion of patients who received such counseling either in the family physicians’ offices or through referral to dietitians. Rural physicians referred patients to dietitian services more frequently than urban physicians did (41.7% vs 21.7% made more than 20 referrals to dietitians each year). Nearly all physicians identified lack of time and compensation as the strongest barriers to providing nutrition guidance. Training was not considered to be as strong a barrier to counseling, even though 82.3% of family physicians reported their formal nutrition training in medical school to be inadequate, and only 30% of family physicians reported currently using any nutrition-related resources. CONCLUSION For family physicians, successful implementation of the 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity requires access to adequate training, compensation, and evidence-based interventions related to nutrition. This study highlights current nutrition counseling practices in family medicine and identifies several obstacles to integrating the current guidelines in primary care settings.

Evaluating Electronic Referrals for Specialty Care at a Public Hospital

Abstract: Poor communication between referring clinicians and specialists may lead to inefficient use of specialist services. San Francisco General Hospital implemented an electronic referral system (eReferral) that facilitates iterative pre-visit communication between referring and specialty clinicians to improve the referral process. The purpose of the study was to determine the impact of eReferral (compared with paper-based referrals) on specialty referrals. The study was based on a visit-based questionnaire appended to new patient charts at randomly selected specialist clinic sessions before and after the implementation of eReferral. Specialty clinicians. The questionnaire focused on the self-reported difficulty in identifying referral question, referral appropriateness, need for and avoidability of follow-up visits. We collected 505 questionnaires from speciality clinicians. It was difficult to identify the reason for referral in 19.8% of medical and 38.0% of surgical visits using paper-based methods vs. 11.0% and 9.5% of those using eReferral (p-value 0.03 and <0.001). Of those using eReferral, 6.4% and 9.8% of medical and surgical referrals using paper methods vs. 2.6% and 2.1% were deemed not completely appropriate (p-value 0.21 and 0.03). Follow-up was requested for 82.4% and 76.2% of medical and surgical patients with paper-based referrals vs. 90.1% and 58.1% of eReferrals (p-value 0.06 and 0.01). Follow-up was considered avoidable for 32.4% and 44.7% of medical and surgical follow-ups with paper-based methods vs. 27.5% and 13.5% with eReferral (0.41 and <0.001). Use of technology to promote standardized referral processes and iterative communication between referring clinicians and specialists has the potential to improve communication between primary care providers and specialists and to increase the effectiveness of specialty referrals.

Standardized Screening for Suicidal Adolescents in Primary Care

Abstract: OBJECTIVE: To determine if brief standardized screening for suicide risk in pediatric primary care practices will increase detection rates of suicidal youth, maintain increased detection and referral rates, and be replicated in other practices. PATIENTS AND METHODS: Physicians in 3 primary care practices received brief training in suicide risk, and 2 standardized questions were inserted into their existing electronic medical chart psychosocial interview. The questions automatically populated for all adolescents aged 12.0 to 17.9 years. Deidentified data were extracted during both intervention trials and for the same dates of the previous year. Referral rates were extracted from social work records. RESULTS: The rates of inquiry about suicide risk increased 219% (clinic A odds ratio [OR]: 2.04 [95% confidence interval (CI): 1.56–2.51]; clinic B OR: 3.20 [95% CI: 2.69–3.71]; clinic C OR: 1.85 [95% CI: 1.38–2.31]). The rate of case detection increased in clinic A (OR: 4.99 [95% CI: 4.20–5.79]), was maintained over 6 months after the intervention began (OR: 4.38 [95% CI: 3.74–5.02]), and was replicated in both clinic B (OR: 5.46 [95% [CI: 3.36–7.56]) and clinic C (OR: 3.42 [95% CI: 2.33–4.52]). The increase in case detection was 392% across all 3 clinics. Referral rates of suicidal youth to outpatient behavioral health care centers increased at a rate equal to that of the detection rates. CONCLUSIONS: Standardized screening for suicide risk in primary care can detect youth with suicidal ideation and prompt a referral to a behavioral health care center before a fatal or serious suicide attempt is made.

Empirical evidence of underutilization of referrals for epilepsy surgery evaluation.

Abstract: Background: Epilepsy surgery is a treatment that can cure patients with intractable epilepsy. This study investigates whether referrals for epilepsy surgery evaluation are underutilized. Methods: Patients with epilepsy aged 18-60 years were identified in a computerized registry held by public health care providers in a Swedish county using ICD codes. Clinical data and data on referral status for epilepsy surgery were obtained from the patients' medical records. Potential candidates for epilepsy surgery evaluation were identified using pre-specified criteria. Obstacles for referral were analysed by comparing clinical data in patients who were considered for referral and those who were not. Appropriateness of non-referral was evaluated against recommendations from the Swedish Council on Technology in Health Care (SBU). Results: Of 378 patients with epilepsy in the registry, 251 agreed to participate. Of 251, 40 were already referred patients and 48 patients were identified as potential candidates for epilepsy surgery evaluation by study criteria. Referral had been considered but not performed in 15 of the potential candidates. Potential candidates not considered for referral were less likely to have seen a neurologist, to have had an EEG, CT and MRI, and more likely to have cognitive disturbances. Following the recommendations by the SBU, 28 of 48 potential candidates were identified as inappropriately not referred patients. Conclusion: The number of missed referrals for epilepsy surgery evaluation was estimated to be 60 per 100 000 inhabitants. Several important obstacles were found for not referring patients for epilepsy surgery evaluation.

Patient Referral Patterns and the Spread of Hospital-Acquired Infections through National Health Care Networks

Abstract: Rates of hospital-acquired infections, such as methicillin-resistant Staphylococcus aureus (MRSA), are increasingly used as quality indicators for hospital hygiene. Alternatively, these rates may vary between hospitals, because hospitals differ in admission and referral of potentially colonized patients. We assessed if different referral patterns between hospitals in health care networks can influence rates of hospital-acquired infections like MRSA. We used the Dutch medical registration of 2004 to measure the connectedness between hospitals. This allowed us to reconstruct the network of hospitals in the Netherlands. We used mathematical models to assess the effect of different patient referral patterns on the potential spread of hospital-acquired infections between hospitals, and between categories of hospitals (University medical centers, top clinical hospitals and general hospitals). University hospitals have a higher number of shared patients than teaching or general hospitals, and are therefore more likely to be among the first to receive colonized patients. Moreover, as the network is directional towards university hospitals, they have a higher prevalence, even when infection control measures are equally effective in all hospitals. Patient referral patterns have a profound effect on the spread of health care-associated infections like hospital-acquired MRSA. The MRSA prevalence therefore differs between hospitals with the position of each hospital within the health care network. Any comparison of MRSA rates between hospitals, as a benchmark for hospital hygiene, should therefore take the position of a hospital within the network into account.

Optimal Referral Bonuses with Asymmetric Information: Firm-Offered and Interpersonal Incentives

Abstract: Referral bonuses, in which an existing customer gets an in-kind or cash reward for referring a new customer, are a popular way to stimulate word of mouth. In this paper, we examine key firm decisions about such bonuses. Others have studied referral bonus programs; a key difference is that we study the role of recommendations not just in spreading awareness as they do but also in providing assessments. We start with the idea that people have a variety of reasons for making product recommendations, including placing a value on a friend's outcome with a product they recommend. We apply that idea in a context of asymmetric information: A customer combines his knowledge about the product and his familiarity with friends' tastes, making him more informed than the friends. Thus, the recommendation is a signal about the value of the product to the friend. In this setting, we consistently find that the greater the concern for others' outcomes, the higher the referral bonus should be, as long as the firm cannot more efficiently motivate recommendations with a lower price. Moreover, if price is the more efficient lever, the optimal bonus is zero, and the optimal price is low. We also show that greater concern tends to reduce firm profit and, in some cases, actually reduces consumer welfare as well.

Smoking prevalence and smoking cessation services for pregnant women in Scotland

Abstract: Over 20% of women smoke throughout pregnancy despite the known risks to mother and child. Engagement in face-to-face support is a good measure of service reach. The Scottish Government has set a target that by 2010 8% of smokers will have quit via NHS cessation services. At present less than 4% stop during pregnancy. We aimed to establish a denominator for pregnant smokers in Scotland and describe the proportion who are referred to specialist services, engage in one-to-one counselling, set a quit date and quit 4 weeks later. This was a descriptive epidemiological study using routinely collected data supplemented by questionnaire information from specialist pregnancy cessation services. 13266 of 52370 (25%) pregnant women reported being current smokers at maternity booking and 3133/13266 (24%) were referred to specialist cessation services in 2005/6. Two main types of specialist smoking cessation support for pregnant women were in place in Scotland. The first involved identification using self-report and carbon monoxide breath test for all pregnant women with routine referral (1936/3352, 58% referred) to clinic based support (386, 11.5% engaged). 370 (11%) women set a quit date and 116 (3.5%) had quit 4 weeks later. The second involved identification by self report and referral of women who wanted help (1195/2776, 43% referred) for home based support (377/1954, 19% engaged). 409(15%) smokers set a quit date and 119 (4.3%) had quit 4 weeks later. Cost of home-based support was greater. In Scotland only 265/8062 (3.2%) pregnant smokers identified at maternity booking, living in areas with recognised specialist or good generic services, quit smoking during 2006. In Scotland, a small proportion of pregnant smokers are supported to stop. Poor outcomes are a product of current limitations to each step of service provision - identification, referral, engagement and treatment. Many smokers are not asked about smoking at maternity booking or provide false information. Carbon monoxide breath testing can bypass this difficulty. Identified smokers may not be referred but an opt-out referral policy can remove this barrier. Engagement at home allowed a greater proportion to set a quit date and quit, but costs were higher.