Showing papers on "Referral published in 2011"

The Psychology of Religion: An Empirical Approach

Abstract: FORMS FOR THE THERAPIST. Allan G. Hedberg (Ed.) (2010). San Diego, CA: Academic Press. Reviewed by Christopher H. Rosik (Link Care Center, Fresno, CA; Fresno Pacific University). Allan Hedberg is a seasoned psychologist and former president of the California Psychological Association. His considerable experience as a clinician is evident in this impressive volume that makes a wealth of useful material readily available to therapists seeking to establish or enhance their practice. Moreover, Dr. Hedberg enlisted the contributions of sixteen other experienced professionals to provide helpful resources in seven areas: Information for the therapist, assessment tools, patient homework or assignment outside therapy, information for the patient, exercises to be performed in therapy, forms to be completed by the therapist or patient, and sample forms and templates. Multiple indexes and pictorial legends help to direct the clinician to the exact page where the needed form is presented. In addition, purchase of the book enables the user to access a website where all of the forms can be downloaded, so no bindingbreaking copying is necessary. It is impossible to review all of the valuable forms compiled in this text, but the list of chapter titles can provide some basic orientation to what this book offers. Chapters include Forms for setting up and defining your practice; Forms related to fees; HIPAA/Patient privacy forms; General information handouts for patients; Forms related to referral and consulting services; Fitness for duty and workers' compensation forms; Forms related to patient services; Forms related to therapist's professional activity; Managing an office staff; Termination of treatment/practice forms; Forms for session notes; Clinical errors, bad habits, ethical complaints, and law suits; Expanding your practice; Organizing your charts and evaluations; General assessments, intake, brief, comprehensive, and more; Assessments related to specific tests and scales; Assessments related to risk, competency, health, and neuropsychology; Anxiety and stress relief with relaxation assessment and exercises; Depression and self-esteem; Insomnia and sleep therapy; Addictive behavior; Suicidal behavior; Pain management and coping with medical disorders; Anger and violent behavior; Strategies and tools for personal growth and health awareness; Communication tips and exercises; eating and exercise logs; Cultural diversity appreciation exercises; Conflict resolution and problem solving; Thinking distortions: Information and patient exercises; eating and exercise logs; Cultural diversity appreciation exercises; Conflict resolution and problem solving; Thinking distortions: Information and patient exercises; Behavioral monitoring logs; Dealing with crisis; Serving children and their families; Dealing with geriatric patients; Couples therapy and relationship assessment and exercises. …

Dropping the baton: specialty referrals in the United States.

Abstract: Context: In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines. Methods: This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care. Findings: PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management). Conclusions: There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.

Referral and Consultation Communication Between Primary Care and Specialist Physicians: Finding Common Ground

Abstract: Background Communication between primary care physicians (PCPs) and specialists regarding referrals and consultations is often inadequate, with negative consequences for patients. We examined PCPs' and specialists' perceptions of communication regarding referrals and consultations. We then identified practice characteristics associated with reported communication. Methods We analyzed the nationally representative 2008 Center for Studying Health System Change Health Tracking Physician Survey of 4720 physicians providing at least 20 hours per week of direct patient care. Outcome measures were physician reports of communication regarding referrals and consultations. Results Perceptions of communication regarding referrals and consultations differed. For example, 69.3% of PCPs reported “always” or “most of the time” sending notification of a patient's history and reason for consultation to specialists, but only 34.8% of specialists said they “always” or “most of the time” received such notification. Similarly, 80.6% of specialists said they “always” or “most of the time” send consultation results to the referring PCP, but only 62.2% of PCPs said they received such information. Physicians who did not receive timely communication regarding referrals and consultations were more likely to report that their ability to provide high-quality care was threatened. The 3 practice characteristics associated with PCPs and specialists reporting communication regarding referrals and consultations were “adequate” visit time with patients, receipt of quality reports regarding patients with chronic conditions, and nurse support for monitoring patients with chronic conditions. Conclusions These modifiable practice supports associated with communication between PCPs and specialists can help inform the ways that resources are focused to improve care coordination.

Barriers to Formal Emergency Obstetric Care Services’ Utilization

Abstract: Access to appropriate health care including skilled birth attendance at delivery and timely referrals to emergency obstetric care services can greatly reduce maternal deaths and disabilities, yet women in sub-Saharan Africa continue to face limited access to skilled delivery services. This study relies on qualitative data collected from residents of two slums in Nairobi, Kenya in 2006 to investigate views surrounding barriers to the uptake of formal obstetric services. Data indicate that slum dwellers prefer formal to informal obstetric services. However, their efforts to utilize formal emergency obstetric care services are constrained by various factors including ineffective health decision making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. As a result, a majority of slum dwellers opt for delivery services offered by traditional birth attendants (TBAs) who lack essential skills and equipment, thereby increasing the risk of death and disability. Based on these findings, we maintain that urban poor women face barriers to access of formal obstetric services at family, community, and health facility levels, and efforts to reduce maternal morbidity and mortality among the urban poor must tackle the barriers, which operate at these different levels to hinder women's access to formal obstetric care services. We recommend continuous community education on symptoms of complications related to pregnancy and timely referral. A focus on training of health personnel on “public relations” could also restore confidence in the health-care system with this populace. Further, we recommend improving the health facilities in the slums, improving the services provided by TBAs through capacity building as well as involving TBAs in referral processes to make access to services timely. Measures can also be put in place to enhance security in the slums at night.

Mapping Physician Networks with Self‐Reported and Administrative Data

Abstract: Relationships between health care providers are essential to a functioning health care system. Physicians rely on their relationships with physician colleagues for patient referrals (Gonzalez and Rizzo 1991), clinical advice (Keating, Zaslavsky, and Ayanian 1998), and information about the latest clinical advances (Gabbay and le May 2004). Given their importance, understanding the nature of such relationships could yield valuable knowledge about the emergence of local practice patterns and the diffusion of health care practices. This understanding could in turn inform health policy decisions aimed at modifying physicians' behavior. Since every doctor has a range of interactions with an array of other doctors, physicians are embedded within a network of relationships, or ties, with their physician colleagues. Using tools from the emerging field of complex network analysis (Newman 2003), physician professional networks defined by such formal or informal relationships can be analyzed at a deeper level than previously possible. Some studies have already begun using these methods to analyze health care networks, addressing topics such as the exchange of clinical advice, the diffusion of pharmaceutical use, or organizational performance and cost-efficiency (Keating et al. 2007; Christakis and Fowler 2010; Iyengar, Van den Bulte, and Valente 2010). A major hurdle to studying physician networks is the lack of data on physician relationships which limits the scope of many studies. For instance, Keating and colleagues studied information seeking among primary care physicians (PCPs) about issues related to women's health, but they studied only 38 doctors whom they surveyed personally. Such de novo survey work requires laborious ascertainment of each relationship among pairs of doctors to map a relationship network, which is a formidable barrier to replication across multiple hospitals or practices. One potential way to identify physician relationships would be to use records regarding patients shared between physicians, as identified in administrative databases. Furthermore, using shared patients to define relationships is clinically intuitive. Physicians often email, phone, or “curbside” a colleague with specific clinical questions or cases, and these informal requests for information are formalized when the patient is actually referred for care (Keating, Zaslavsky, and Ayanian 1998). Thus, the presence of shared patients in administrative data—arising because of referral, patient self-selection, administrative rules (e.g., insurer policies regarding second opinions), or even chance—may represent an important source of information about physician relationships that could be useful for large-scale studies using the tools of network science. In this study, we sought to validate the use of patient sharing identified in administrative data as a source of information on physician networks. To do so, we first identified physicians connected via shared patients in Medicare data. We then surveyed physicians in a large physicians' organization and asked them about their referral and information-sharing relationships with other physicians and evaluated the correspondence between those relationships and patient sharing measured by Medicare claims.

Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study.

Abstract: Background Although cardiac rehabilitation (CR) has been shown to reduce mortality and is a recommended component in clinical practice guidelines, CR referral and utilization rates remain low. Referral strategies have been implemented to increase CR use but have yet to be compared concurrently. To determine the optimal strategy to maximize CR referral, enrollment, and participation, we evaluated 3 referral strategies compared with usual care: “automatic” only via discharge order or electronic record, health care provider liaison only, or a combined approach. Methods In this prospective controlled study, 2635 inpatients with coronary artery disease from 11 Ontario, Canada, hospitals using 1 of the 4 referral strategies completed a sociodemographic survey, and clinical data were extracted from medical charts. One year later, 1809 participants completed a mailed survey that assessed CR utilization. Referral strategies were compared using generalized estimating equations to control for effect of hospital. Results Adjusted analyses revealed referral strategy was significantly related to CR referral and enrollment ( P P = .88). Conclusions Automatic referral combined with a patient discussion can achieve among the highest rates of CR referral reported. Wider adoption of such strategies could ensure that 45% more patients being treated for cardiac disease would have access to and realize the benefits of CR.

Substance use screening, brief intervention, and referral to treatment for pediatricians.

Abstract: As a component of comprehensive pediatric care, adolescents should receive appropriate guidance regarding substance use during routine clinical care. This statement addresses practitioner challenges posed by the spectrum of pediatric substance use and presents an algorithm-based approach to augment the pediatrician's confidence and abilities related to substance use screening, brief intervention, and referral to treatment in the primary care setting. Adolescents with addictions should be managed collaboratively (or comanaged) with child and adolescent mental health or addiction specialists. This statement reviews recommended referral guidelines that are based on established patient-treatment-matching criteria and the risk level for substance abuse.

Multidisciplinary Team Care May Slow the Rate of Decline in Renal Function

Abstract: Summary Background and objectives A multidisciplinary team (MDT) approach to chronic kidney disease (CKD) may help optimize care of CKD and comorbidities. We implemented an MDT quality improvement project for persons with stage 3 CKD and comorbid diabetes and/or hypertension. Our objective was to decrease the rate of decline of GFR. Design, setting, participants, & measurements We used a 4-year historical cohort to compare 1769 persons referred for usual nephrology care versus 233 referred for MDT care within an integrated, not-for-profit Health Maintenance Organization (HMO). Usual care consisted of referral to an outside nephrologist. The MDT consisted of an HMO-based nephrologist, pharmacy specialist, diabetes educator, dietitian, social worker, and nephrology nurse. Both groups received usual primary care. The primary outcome was rate of decline of GFR. Secondary outcomes were LDL, hemoglobin A1c, and BP. Results In multivariate repeated-measures analyses, MDT care was associated with a mean annual decline in GFR of 1.2 versus 2.5 ml/min per 1.73 m 2 for usual care. In stratified analyses, the significant difference in GFR decline persisted only in those who completed their referrals. There were no differences in the secondary outcomes between groups. Conclusions In this integrated care setting, MDT care resulted in a slower decline in GFR than usual care. This occurred despite a lack of significant differences for secondary disease-specific measures, suggesting that other differences in the MDT population or care process accounted for the slower decline in GFR in the MDT group. Clin J Am Soc Nephrol 6: ●●● –●●● , 2011. doi: 10.2215/CJN.06610810

HIV partner notification is effective and feasible in sub-Saharan Africa: opportunities for HIV treatment and prevention.

Abstract: BACKGROUND: Sexual partners of persons with newly diagnosed HIV infection require HIV counseling testing and if necessary evaluation for therapy. However many African countries do not have a standardized protocol for partner notification and the effectiveness of partner notification has not been evaluated in developing countries . METHODS: Individuals with newly diagnosed HIV infection presenting to sexually transmitted infection clinics in Lilongwe Malawi were randomized to 1 of 3 methods of partner notification: passive referral contract referral or provider referral. The passive referral group was responsible for notifying their partners themselves. The contract referral group was given seven days to notify their partners after which a health care provider contacted partners who had not reported for counseling and testing. In the provider referral group a health care provider notified partners directly. RESULTS: Two hundred forty-five index patients named 302 sexual partners and provided locator information for 252. Among locatable partners 107 returned for HIV counseling and testing; 20 of 82 [24%; 95% confidence interval (CI): 15% to 34%] partners returned in the passive referral arm 45 of 88 (51%; 95% CI: 41% to 62%) in the contract referral arm and 42 of 82 (51%; 95% CI: 40% to 62%) in the provider referral arm (P < 0.001). Among returning partners (n = 107) 67 (64%) of were HIV infected with 54 (81%) newly diagnosed. DISCUSSION: This study provides the first evidence of the effectiveness of partner notification in sub-Saharan Africa. Active partner notification was feasible acceptable and effective among sexually transmitted infections clinic patients. Partner notification will increase early referral to care and facilitate risk reduction among high-risk uninfected partners.

Stimulant Abuse: Pharmacology, Cocaine, Methamphetamine, Treatment, Attempts at Pharmacotherapy

Abstract: The high prevalence of stimulant abuse and its harmful consequences make the screening, diagnosis, and referral for treatment of persons with stimulant abuse a top concern for primary care providers. Having a working knowledge of use patterns, clinical symptomatology, end-organ effects, and advances in treatment of stimulant abuse is essential. Although cocaine and amphetamine have different use patterns, duration of action, and so forth, the consequences of use are remarkably similar. Primary care is at the forefront of screening, brief risk reduction interventions, and diagnosis of medical sequelae, with referral to addiction specialist treatment when necessary.

A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: A cluster randomised trial

Abstract: Background: In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated. Methods and Findings: This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n=4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n=4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline. In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean=0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05–0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%; 17.1% [8.04%–26.1%]); loading dose quinine (91.9% versus 66.7%, 26.3% [23.66% to 56.3%]); and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%; 29.9% [10.9%–48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose .40 mg/ kg/day; 1.0% versus 7.5%; 26.5% [212.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%; 26.8% [211.9% to 21.6%]). Conclusions: Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings. Trial registration: Current Controlled Trials ISRCTN42996612 Please see later in the article for the Editors’ Summary.

Interventions for improving palliative care for older people living in nursing care homes

Abstract: Background Residents of nursing care homes for older people are highly likely to die there, making these places where palliative care is needed. Objectives The primary objective was to determine effectiveness of multi-component palliative care service delivery interventions for residents of care homes for older people. The secondary objective was to describe the range and quality of outcome measures. Search methods The grey literature and the following electronic databases were searched: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness (all issue 1, 2010); MEDLINE, EMBASE, CINAHL, British Nursing Index, (1806 to February 2010), Science Citation Index Expanded & AMED (all to February 2010). Key journals were hand searched and a PubMed related articles link search was conducted on the final list of articles. Selection criteria We planned to include Randomised Clinical Trials (RCTs), Controlled Clinical Trials (CCTs), controlled before-and-after studies and interrupted time series studies of multi-component palliative care service delivery interventions for residents of care homes for older people. These usually include the assessment and management of physical, psychological and spiritual symptoms and advance care planning. We did not include individual components of palliative care, such as advance care planning. Data collection and analysis Two review authors independently assessed studies for inclusion, extracted data, and assessed quality and risk of bias. Meta analysis was not conducted due to heterogeneity of studies. The analysis comprised a structured narrative synthesis. Outcomes for residents and process of care measures were reported separately. Main results Two RCTs and one controlled before-and-after study were included (735 participants). All were conducted in the USA and had several potential sources of bias. Few outcomes for residents were assessed. One study reported higher satisfaction with care and the other found lower observed discomfort in residents with end-stage dementia. Two studies reported group differences on some process measures. Both reported higher referral to hospice services in their intervention group, one found fewer hospital admissions and days in hospital in the intervention group, the other found an increase in do-not-resuscitate orders and documented advance care plan discussions. Authors' conclusions We found few studies, and all were in the USA. Although the results are potentially promising, high quality trials of palliative care service delivery interventions which assess outcomes for residents are needed, particularly outside the USA. These should focus on measuring standard outcomes, assessing cost-effectiveness, and reducing bias.

Allergic reactions during anesthesia at a large United States referral center.

Abstract: BACKGROUND:The types of agents implicated to trigger intraoperative anaphylactic reactions vary among reports, and there are no recent series from the United States. In this retrospective study, we examined perioperative anaphylactic reactions that occurred at a major tertiary referral academic cent

Weight Watchers on prescription: An observational study of weight change among adults referred to Weight Watchers by the NHS

Abstract: The scale of overweight and obesity in the UK places a considerable burden on the NHS. In some areas the NHS has formed partnerships with commercial companies to offer weight management services, but there has been little evaluation of these schemes. This study is an independent audit of the Weight Watchers NHS Referral scheme and evaluates the weight change of obese and overweight adults referred to Weight Watchers (WW) by the NHS. Data was obtained from the WW NHS Referral Scheme database for 29,326 referral courses started after 2nd April 2007 and ending before 6th October 2009 [90% female; median age 49 years (IQR 38 - 61 years); median BMI 35.1 kg/m2 (IQR 31.8 - 39.5 kg/m2). Participants received vouchers (funded by the PCT following referral by a healthcare professional) to attend 12 WW meetings. Body weight was measured at WW meetings and relayed to the central database. Median weight change for all referrals was -2.8 kg [IQR -5.9 - -0.7 kg] representing -3.1% initial weight. 33% of all courses resulted in loss of ≥5% initial weight. 54% of courses were completed. Median weight change for those completing a first course was -5.4 kg [IQR -7.8 - -3.1 kg] or -5.6% of initial weight. 57% lost ≥5% initial weight. A third of all patients who were referred to WW through the WW NHS Referral Scheme and started a 12 session course achieved ≥5% weight loss, which is usually associated with clinical benefits. This is the largest audit of NHS referral to a commercial weight loss programme in the UK and results are comparable with other options for weight loss available through primary care.

UK guidelines for referral and assessment of adults for heart transplantation

Abstract: Patients with advanced heart failure have a dismal prognosis and poor quality of life. Heart transplantation provides an effective treatment for a subset of these patients. This article provides cardiologists with up-to-date information about referral for transplantation, the role of left ventricular assist devices prior to transplant, patient selection, waiting-list management and donor heart availability. Timing is of central importance; patients should be referred before complications (eg, cardiorenal syndrome or secondary pulmonary hypertension) have developed that will increase the risk of, or potentially contraindicate, transplantation. Issues related to heart failure aetiology, comorbidity and adherence to medical treatment are reviewed. Finally, the positive role that cardiologists can play in promoting and facilitating organ donation is discussed.

Evaluation of 2 Screening Strategies for Early Identification of Patients with Axial Spondyloarthritis in Primary Care

Abstract: Objective. To evaluate 2 referral strategies for axial spondyloarthritis (SpA) in patients with chronic low back pain at the primary care level. Methods. Referral physicians (n = 259) were randomly assigned to either Strategy 1 or Strategy 2 in order to refer patients with chronic back pain (duration > 3 months), age at onset of back pain Results. In total, 560 consecutively referred patients were included in the analysis. Among 318 patients referred by Strategy 1, 41.8% (95% CI 36.5%–47.3%) were diagnosed with definite axial SpA. Among 242 patients referred by the second strategy, definite axial SpA was diagnosed in 36.8% (95% CI 31.0%–43.0%) of the cases. Conclusion. Both referral strategies demonstrated comparable performance in identification of patients with axial SpA. Strategy 1 might be preferred as an easy and reliable screening method for axial SpA at the primary care level.

Accelerating the Academic Achievement of Students Referred to Developmental Education. CCRC Working Paper No. 30.

Abstract: Acceleration, which involves the reorganization of instruction and curricula in ways that facilitate the completion of academic requirements in an expedited manner, is an increasingly popular strategy at community colleges for improving the outcomes of developmental education students. This paper reviews the literature on acceleration and considers the quality of evidence available on the effects of acceleration on student outcomes. After examining various definitions of acceleration to better understand what it is and how it works, the paper describes and categorizes the different acceleration models in use. Then, the recent empirical literature on acceleration is reviewed to assess the effectiveness of these approaches. While the empirical basis for acceleration is not as strong as is desirable, existing evidence suggests that there are a variety of models of course redesign and mainstreaming that community colleges can employ to enhance student outcomes. The paper closes with a discussion of the challenges involved in implementing acceleration strategies and recommendations for policy, practice, and research.

Which patients and where: a qualitative study of patient transfers from community hospitals.

Abstract: Background—Interhospital transfer of patients is a routine part of the care at community hospitals, but the current process may lead to sub-optimal patient outcomes. A micro-level analysis of the processes of patient transfer has not previously been performed. Research Design—We carried out semi-structured qualitative interviews with care providers at 3 purposively sampled community hospitals in order to describe patient transfer mechanisms, focusing on perceptions of transfers and transfer candidates, choice of transfer destination, and perceived process. We interviewed physicians, nurses and care technicians from emergency departments and intensive care units at the hospitals, and analyzed the resultant transcripts via content analysis. Results—Appropriate triage and transfer of patients was a highly valued skill at community hospitals. Based on participant accounts, the transfer process had four components: (1) Identifying Transfer-Eligible Patients; (2) Identifying a Destination Hospital; (3) Negotiating the Transfer; and (4) Accomplishing the Transfer. There were common challenges at each component across hospitals. Protocolization of care was perceived to substantially facilitate transfers. Informal arrangements played a key role in the identification of the receiving hospital, but patient preferences and hospital quality were not discussed as important in decision-making. The process of arranging a patient transfer placed a significant burden on the staff of community hospitals. Conclusions—The patient transfer process is often cumbersome, varies by condition, and may not be focused on optimizing patient outcomes. Development of a more fluid transfer infrastructure may aid in implementing policies such as selective referral and regionalization. Interhospital patient transfers are a routine and essential part of the care of many patients, both from the Emergency Department (ED) (1–3) and the wider hospital. Even among critically ill patients admitted to an intensive care unit (ICU) in the US, nearly 1 in 20 will be transferred to another hospital’s ICU, (4, 5) and transfers are similarly common in the UK. (6, 7) Transfer rates for patients with acute myocardial infarction (AMI) admitted to community hospitals approach 50% in the US. (8, 9) Transfers occur because capacity, capabilities, and expertise are unevenly distributed between hospitals. The transfer system is routinely assumed to be an available infrastructure that can be used easily. Indeed, a smoothly functioning transfer system is assumed in an array of common health policies, from disaster management for individual hospitals to health care reforms such as selective referral. (10, 11) Despite the potential importance of transfers, existing transfer patterns appear suboptimal. Both the American Heart Association and the American College of Surgeons have programs to correct perceived failures in the identification of patients who would benefit from transfer

Patient satisfaction with services in outpatient clinics at Mulago hospital, Uganda.

Abstract: Objectives. To identify factors associated with general satisfaction among clients attending outpatient clinics in a referral hospital in Uganda. Design. Cross-sectional exit survey of patients and care-givers in selected outpatient clinics. Setting. Seven outpatients’ clinics at Mulago National Referral and Teaching Hospital. Main Outcome Measures. Mean score of clients’ general satisfaction with health-care services. Results. Overall the clients’ general satisfaction was suboptimal. Average satisfaction was higher among clients with a primary or secondary education compared with none, those attending HIV treatment and research clinic compared with general outpatient clients, and returning relative to new clients. Conversely, satisfaction was lower among clients incurring costs of at least $1.5 during the visit, and those reporting longer waiting time (.2 h). Client’s perceived technical competence of provider, accessibility, convenience and availability of services especially prescribed drugs were the strongest predictor of general satisfaction. Conclusions. This study highlights the important findings about outpatient services at Mulago hospital. The sub-optimal satisfaction scores for outpatient care strongly suggest that more could be done to assure that services provided are more patient centered. Significant factors including category of clinic visited, waiting time, costs incurred, accessibility of services and perceived providers’ technical competence at this hospital should be explored by the Makerere University College of Health Sciences and Mulago hospital for potential improvements in quality of the health service delivered.

Mothers' satisfaction with referral hospital delivery service in Amhara Region, Ethiopia

Abstract: A woman's satisfaction with the delivery service may have immediate and long-term effects on her health and subsequent utilization of the services. Providing satisfying delivery care increases service utilization. The objective of this study is to assess the satisfaction of mothers with referral hospitals' delivery service and identify some possible factors affecting satisfaction in Amhara region of Ethiopia. A hospital-based cross-sectional survey that involved an exit interview was conducted from September to November 2009 in three referral hospitals in Ethiopia. A total of 417 delivering mothers were enrolled in the study. Client satisfaction was measured using a survey instrument adopted from the Donabedian quality assessment framework. We collect data systematically from every other postnatal woman who delivered in the referral hospitals. Multivariate and binary logistic regression was applied to identify the relative effect of each explanatory variable on the outcome (satisfaction). The proportion of mothers who were satisfied with delivery care in this study was 61.9%. Women's satisfaction with delivery care was associated with wanted status of the pregnancy, immediate maternal condition after delivery, waiting time to see the health worker, availability of waiting area, care providers' measure taken to assure privacy during examinations, and amount of cost paid for service. The overall satisfaction of hospital delivery services in this study is found to be suboptimal. The study strongly suggests that more could be done to assure that services provided are more patient centered.

Mental health screening and follow-up care in public high schools.

Abstract: Objective Despite increased interest in screening adolescents for mental health problems and suicide risk, little is known regarding the extent to which youth are identified and connected with appropriate services. Method Between 2005 and 2009, a total of 4,509 ninth-grade students were offered screening. We reviewed the records of the 2,488 students who were screened. Students identified as being at risk were provided with a referral. Data were collected on screening results, mental health referrals, and completion of recommended treatment over approximately 90 days. Results Among students screened, 19.6% were identified as being at risk, 73.6% of whom were not currently receiving any treatment. Students referred for school services tended to be less severely ill than those referred for community services, with lower rates of suicidal ideation, prior suicide attempts, and self-injury. Among at-risk students not currently in treatment, 76.3% of students referred received at least one mental health visit during the follow-up period. Overall, 74.0% of students were referred to school and 57.3% to community services. A great majority of school referrals (80.2%) successfully accessed services, although a smaller proportion of community services referrals successfully accessed treatment (41.9%). Conclusions Systematic voluntary school-based mental health screening and referral offers a feasible means of identifying and connecting high-risk adolescents to school- and community-based mental health services, although linkages to community-based services may require considerable coordination.

How infants die in the neonatal intensive care unit: trends from 1999 through 2008.

Abstract: Objective To determine whether trends toward decreasing use of cardiopulmonary resuscitation at the time of death and increasing frequency of forgoing life-sustaining treatment had continued, as few studies quantifying mode of death for hospitalized infants have been conducted in the last 10 years Design Retrospective descriptive study Setting Regional referral neonatal intensive care unit Participants Infants who died from January 1, 1999, to December 31, 2008 Infants were categorized into following categories: (1) very preterm (≤32 weeks' gestation); (2) congenital anomaly; and (3) other Main Outcome Measures The primary outcome was level of clinical service provided at the end of life (care withheld, care withdrawn, or full resuscitation) Results For 10 years, 414 neonatal patients died Of these, 616% had care withdrawn, 208% had care withheld, and 176% received cardiopulmonary resuscitation The percentage of deaths that followed withholding of treatment rose by 1% per year (P = 01) Most of this change was accounted for by withholding of therapy in the very premature group Conclusion During the 10-year period, the primary mode of death in this regional referral neonatal intensive care unit was withdrawal of life-sustaining support When death is imminent or medical care is considered futile, the approach is thought to provide a peaceful, controlled setting Significant increase in withholding of care suggests improved recognition of medical futility and desire to provide a peaceful death

Military sexual trauma.

Abstract: Nurses' awareness of MST as a specific type of sexual assault within the military culture and sensitivity to the physical and psychological symptoms are important aspects of care. Nurses must treat the physical and emotional components of sexual assault in all settings; however, referral to the veterans administration programs and resources is key for the woman veteran to receive the specialized care developed by the healthcare system. Women veterans who have PTSD from MST and combat exposure are prone to depression, suicide and substance use/abuse. Nurses must not fear asking the woman if she is having suicidal thoughts or has a plan and intent to follow through with the plan. MST and PTSD may result in internalized anger, shame, self-blame, helplessness, hopelessness and powerlessness. Patient safety is of utmost importance. Assessing Patients for Sexual Violence, A Guide for Health Care Providers (2009) is a useful resource for nurses. The National Center for PTSD (2009) newsletter on the topic of MST includes a list of research studies. The work of Benedict (2007) and Corbett (2007) provide additional personal accounts of women soldiers who were in the Middle East conflicts. The nurse's referral to specialized services to treat MST and PTSD with evidence-based therapies is a crucial first step in the resiliency and well-being of these brave women who have served in all branches of the U.S. military.

Reported referral for genetic counseling or BRCA 1/2 testing among United States physicians

Abstract: BACKGROUND: Genetic counseling and testing is recommended for women at high but not average risk of ovarian cancer. National estimates of physician adherence to genetic counseling and testing recommendations are lacking. METHODS: Using a vignette-based study, we surveyed 3200 United States family physicians, general internists, and obstetrician/gynecologists and received 1878 (62%) responses. The questionnaire included an annual examination vignette asking about genetic counseling and testing. The vignette varied patient age, race, insurance status, and ovarian cancer risk. Estimates of physician adherence to genetic counseling and testing recommendations were weighted to the United States primary care physician population. Multivariable logistic regression identified independent patient and physician predictors of adherence. RESULTS: For average-risk women, 71% of physicians self-reported adhering to recommendations against genetic counseling or testing. In multivariable modeling, predictors of adherence against referral/testing included black versus white race (relative risk [RR], 1.16; 95% confidence interval [CI], 1.03-1.31), Medicaid versus private insurance (RR, 1.15; 95% CI, 1.02-1.29), and rural versus urban location. Among high-risk women, 41% of physicians self-reported adhering to recommendations to refer for genetic counseling or testing. Predictors of adherence for referral/testing were younger patient age [35 vs 51 years [RR, 1.78; 95% CI, 1.41-2.24]), physician sex (female vs male [RR, 1.30; 95% CI, 1.07-1.64]), and obstetrician/gynecologist versus family medicine specialty (RR, 1.64; 95% CI, 1.31-2.05). For both average-risk and high-risk women, physician-estimated ovarian cancer risk was the most powerful predictor of recommendation adherence. CONCLUSION: Physicians reported that they would refer many average-risk women and would not refer many high-risk women for genetic counseling/testing. Intervention efforts, including promotion of accurate risk assessment, are needed. Cancer 2011;. © 2011 American Cancer Society.