Showing papers on "Referral published in 2012"

The burden of endometriosis: costs and quality of life of women with endometriosis and treated in referral centres

Abstract: methods: A prospective, multi-centre, questionnaire-based survey measured costs and quality of life in ambulatory care and in 12 tertiary care centres in 10 countries. The study enrolled women with a diagnosis of endometriosis and with at least one centre-specific contact related to endometriosis-associated symptoms in 2008. The main outcome measures were health care costs, costs of productivity loss, total costs and quality-adjusted life years. Predictors of costs were identified using regression analysis. results: Data analysis of 909 women demonstrated that the average annual total cost per woman was E9579 (95% confidence interval E8559–E10 599). Costs of productivity loss of E6298 per woman were double the health care costs of E3113 per woman. Health care costs were mainly due to surgery (29%), monitoring tests (19%) and hospitalization (18%) and physician visits (16%). Endometriosis-associated symptoms generated 0.809 quality-adjusted life years per woman. Decreased quality of life was the most important predictor of direct health care and total costs. Costs were greater with increasing severity of endometriosis, presence of pelvic pain, presence of infertility and a higher number of years since diagnosis. conclusions: Our study invited women to report resource use based on endometriosis-associated symptoms only, rather than drawing on a control population of women without endometriosis. Our study showed that the economic burden associated with endometriosis treated in referral centres is high and is similar to other chronic diseases (diabetes, Crohn’s disease, rheumatoid arthritis). It arises predominantly from productivity loss, and is predicted by decreased quality of life.

Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients With Metastatic Non–Small-Cell Lung Cancer

Abstract: Purpose Prior research shows that introducing palliative care soon after diagnosis for patients with metastatic non–small-cell lung cancer (NSCLC) is associated with improvements in quality of life, mood, and survival. We sought to investigate whether early palliative care also affects the frequency and timing of chemotherapy use and hospice care for these patients. Patients and Methods This secondary analysis is based on a randomized controlled trial of 151 patients with newly diagnosed metastatic NSCLC presenting to an outpatient clinic at a tertiary cancer center from June 2006 to July 2009. Participants received either early palliative care integrated with standard oncology care or standard oncology care alone. By 18-month follow-up, 133 participants (88.1%) had died. Outcome measures included: first, number and types of chemotherapy regimens, and second, frequency and timing of chemotherapy administration and hospice referral. Results The overall number of chemotherapy regimens did not differ signifi...

Sex and gender differences in health: Science & Society Series on Sex and Science

Abstract: Men and women are alike in many ways. However, there are important biological and behavioural differences between the two genders. They affect manifestation, epidemiology and pathophysiology of many widespread diseases and the approach to health care. Despite our knowledge of these crucial differences, there is little gender‐specific health care; the prevention, management and therapeutic treatment of many common diseases does not reflect the most obvious and most important risk factors for the patient: sex and gender. This omission is holding back more efficient health care, as gender‐based prevention measures or therapies are probably more effective than the usual ‘one‐size‐fits all’ approach and would benefit patients of both genders. Addressing gender in health and health care therefore requires new approaches at many levels, from training medical personal to clinical medicine, epidemiology and drug development. > …the prevention, management and therapeutic treatment of many common diseases does not reflect the most obvious and most important risk factors for the patient: sex and gender To discuss and address properly the differences in health and health care between men and women, it is necessary to distinguish between sex and gender and their respective effects on health. Sex differences are based on biological factors. These include reproductive function, concentrations of sexual hormones, the expression of genes on X and Y chromosomes and their effects and the higher percentage of body fat in women. By contrast, gender is associated with behaviour, lifestyle and life experience. It determines access to health care, use of the health care system and the behavioural attitudes of medical personnel. Typical gender differences in health care include differences in the use of preventive measures, the prescription of drugs, health insurance reimbursement and referral for or acceptance of particular surgical therapies such as pacemaker implantation or heart transplantation. > Gender medicine must consider the needs …

General Practice and Primary Health Care in Denmark

Abstract: General practice is the corner stone of Danish primary health care. General practitioners (GPs) are similar to family physicians in the United States. On average, all Danes have 6.9 contacts per year with their GP (in-person, telephone, or E-mail consultation). General practice is characterized by 5 key components: (1) a list system, with an average of close to 1600 persons on the list of a typical GP; (2) the GP as gatekeeper and first-line provider in the sense that a referral from a GP is required for most office-based specialists and always for in- and outpatient hospital treatment; (3) an after-hours system staffed by GPs on a rota basis; (4) a mixed capitation and fee-for-service system; and (5) GPs are self-employed, working on contract for the public funder based on a national agreement that details not only services and reimbursement but also opening hours and required postgraduate education. The contract is (re)negotiated every 2 years. General practice is embedded in a universal tax-funded health care system in which GP and hospital services are free at the point of use. The current system has evolved over the past century and has shown an ability to adapt flexibly to new challenges. Practice units are fairly small: close to 2 GPs per unit plus nurses and secretaries. The units are fully computerized, that is, with computer-based patient records and submission of prescriptions digitally to pharmacies etc. Over the past few years a decrease in solo practices has been seen and is expected to accelerate, in part because of the GP age structure, with many GPs retiring and new GPs not wanting to practice alone. This latter workforce trend is pointing toward a new model with employed GPs, particularly in rural areas.

Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force

Abstract: This review examined the effectiveness of screening followed by behavioral counseling, with or without referral, for alcohol misuse in primary care settings. Among 23 included trials, brief multico...

The Asheville Project: Short-Term Outcomes of a Community Pharmacy Diabetes Care Program

Abstract: Objectives: To assess short-term clinical, economic, and humanistic outcomes of pharmaceutical care services (PCS) for patients with diabetes in community pharmacies Design: Intention-to-treat, pre–post cohort-with-comparison group study. Setting: Twelve community pharmacies in Asheville, N.C. Patients and Other Participants: Eighty-five patients with diabetes who were employees, dependents, or retirees from two self-insured employers; community pharmacists who completed a diabetes certificate program and received reimbursement for PCS. Interventions: Patients scheduled consultations with pharmacists over 7 to 9months. Pharmacists provided education, self-monitored blood glucose (SMBG) meter training, clinical assessment, patient monitoring, follow-up, and referral. Group 1 patients began receiving PCS in March 1997, and group 2 patients began in March 1999. Main Outcome Measures: Change from baseline in the two employer groups in glycosylated hemoglobin (A1c) values, serum lipid concentrations, health-related quality of life (HRQOL), satisfaction with pharmacy services, and health care utilization and costs. Results: Patients used SMBG meters at home, stored all readings, and brought their meters with them to 87% of the 317 PCS visits (3.7 visits per patient). Patients‘ A1c concentrations were significantly reduced, and their satisfaction with pharmacy services improved significantly. Patients experienced no change in HRQOL. From the payers' perspective, there was a significant $52 per patient per month increase in diabetes costs for both groups, with PCS fees and diabetes prescriptions accounting for most of the increase. In contrast, both groups experienced a nonsignificant but economically important 29% decrease in nondiabetes costs and a 16% decrease in all-diagnosis costs. Conclusion: A clear temporal relationship was found between PCS and improved A1c, improved patient satisfaction with pharmacy services, and decreased all-diagnosis costs. Findings from this study demonstrate that pharmacists provided effective cognitive services and refute the idea that pharmacists must be certified diabetes educators to help patients with diabetes improve clinical outcomes.

NHS Diabetes guideline for the perioperative management of the adult patient with diabetes.

Abstract: These Joint British Diabetes Societies guidelines, commissioned by NHS Diabetes, for the perioperative management of the adult patient undergoing surgery are available in full in the Supporting Information. This document goes through the seven stages of the patient journey when having surgery. These are: primary care referral; surgical outpatients; preoperative assessment; hospital admission; surgery; post-operative care; discharge. Each stage is given its own considerations, outlining the roles and responsibilities of each group of healthcare professionals. The evidence base for the recommendations made at each stage, discussion of controversial areas and references are provided in the report. This document has two key recommendations. Firstly, that the management of the elective adult surgery patients should be with modification to their usual diabetes treatment if the fasting is minimized because the routine use of a variable rate intravenous insulin infusion is not recommended. Secondly, that poor preoperative glycaemic control leads to post-outcomes and thus, where appropriate, needs to be addressed prior to referral for surgery.

Referral Practices of Oncologists to Specialized Palliative Care

Abstract: Purpose To describe current referral practices of oncologists to specialized palliative care (SPC) and define demographic characteristics, practice situations, and opinions associated with referral. Methods Physician members of the Canadian Association of Medical Oncologists, Canadian Association of Radiation Oncologists, and Canadian Society of Surgical Oncology were invited to participate in an anonymous survey assessing SPC referral practices. Participants received two e-mailed and two mailed invitations. Results The response rate was 72% (603 of 839 physicians); 37% were medical oncologists/hematologists, 50% were radiation oncologists, and 12% were surgical oncologists. Ninety-four percent reported that SPC was available to them, but only 37% reported that these services accepted patients on chemotherapy. Eighty-four percent referred terminally ill patients usually/always, but generally for uncontrolled symptoms or discharge planning late in the disease course. One third would refer to SPC earlier if...

Trends in Physician Referrals in the United States, 1999-2009

Abstract: Background Physician referrals play a central role in ambulatory care in the United States; however, little is known about national trends in physician referrals over time. The objective of this study was to assess changes in the annual rate of referrals to other physicians from physician office visits in the United States from 1999 to 2009. Methods We analyzed nationally representative cross-sections of ambulatory patient visits in the United States, using a sample of 845 243 visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1993 to 2009, focusing on the decade from 1999 to 2009. The main outcome measures were survey-weighted estimates of the total number and percentage of visits resulting in a referral to another physician across several patient and physician characteristics. Results From 1999 to 2009, the probability that an ambulatory visit to a physician resulted in a referral to another physician increased from 4.8% to 9.3% (P Conclusions The percentage and absolute number of ambulatory visits resulting in a referral in the United States grew substantially from 1999 to 2009. More research is necessary to understand the contribution of rising referral rates to costs of care.

Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs.

Abstract: Study design A retrospective cohort. Objective To describe physical therapy utilization following primary care consultation for low back pain (LBP) and evaluate associations between the timing and content of physical therapy and subsequent health care utilization and costs. Summary of background data Primary care management of LBP is highly variable and the implications for subsequent costs are not well understood. The importance of referring patients from primary care to physical therapy has been debated, and information on how the timing and content of physical therapy impact subsequent costs and utilization is needed. Methods Data were extracted from a national database of employer-sponsored health plans. A total of 32,070 patients with a new primary care LBP consultation were identified and categorized on the basis of the use of physical therapy within 90 days. Patients utilizing physical therapy were further categorized based on timing (early [within 14 d] or delayed)] and content (guideline adherent or nonadherent). LBP-related health care costs and utilization in the 18-months following primary care consultation were examined. Results Physical therapy utilization was 7.0% with significant geographic variability. Early physical therapy timing was associated with decreased risk of advanced imaging (odds ratio [OR] = 0.34, 95% confidence interval [CI]: 0.29, 0.41), additional physician visits (OR = 0.26, 95% CI: 0.21, 0.32), surgery (OR = 0.45, 95% CI: 0.32, 0.64), injections (OR = 0.42, 95% CI: 0.32, 0.64), and opioid medications (OR = 0.78, 95% CI: 0.66, 0.93) compared with delayed physical therapy. Total medical costs for LBP were $2736.23 lower (95% CI: 1810.67, 3661.78) for patients receiving early physical therapy. Physical therapy content showed weaker associations with subsequent care. Conclusion Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy. Further research is needed to clarify exactly which patients with LBP should be referred to physical therapy; however, if referral is to be made, delaying the initiation of physical therapy may increase risk for additional health care consumption and costs.

Practical consensus guidelines for the management of enuresis

Abstract: Despite the high prevalence of enuresis, the professional training of doctors in the evaluation and management of this condition is often minimal and/or inconsistent. Therefore, patient care is neither optimal nor efficient, which can have a profound impact on affected children and their families. Once comprehensive history taking and evaluation has eliminated daytime symptoms or comorbidities, monosymptomatic enuresis can be managed efficaciously in the majority of patients. Non-monosymptomatic enuresis is often a more complex condition; these patients may benefit from referral to specialty care centers. We outline two alternative strategies to determine the most appropriate course of care. The first is a basic assessment covering only the essential components of diagnostic investigation which can be carried out in one office visit. The second strategy includes several additional evaluations including completion of a voiding diary, which requires extra time during the initial consultation and two office visits before treatment or specialty referral is provided. This should yield greater success than first-line treatment. Conclusion: This guideline, endorsed by major international pediatric urology and nephrology societies, aims to equip a general pediatric practice in both primary and secondary care with simple yet comprehensive guidelines and practical tools (i.e., checklists, diary templates, and quick-reference flowcharts) for complete evaluation and successful treatment of enuresis.

Increasing Referral and Participation Rates to Outpatient Cardiac Rehabilitation: The Valuable Role of Healthcare Professionals in the Inpatient and Home Health Settings A Science Advisory From the American Heart Association

Abstract: Cardiovascular disease (CVD) continues to be the leading cause of morbidity and mortality in the United States and worldwide1 In fact, the prevalence of CVD is on the rise as a function of increased longevity and the mounting effects of cardiac risk factors that typically accumulate over a lifetime Outpatient cardiac rehabilitation (CR) programs offer a cost-effective, multidisciplinary, comprehensive approach to address these risk factors and to restore individuals to their optimal physiological, psychosocial, nutritional, and functional status2–6 Thus, the benefits of CR extend well beyond the cardiovascular system, positively affecting an individual's overall health status These benefits may be particularly important to certain CVD cohorts such as elderly patients who are more likely to present with greater functional limitations and frailty Additionally, outpatient CR has been shown to dramatically reduce morbidity and mortality by nearly 25% compared with usual care7,8 Despite the clear benefits of formal, supervised outpatient CR and exercise training programs, as well as strides in automatic referrals,9 current statistics continue to demonstrate that referral and participation rates of eligible patients remain alarmingly low,10–13 with participation particularly poor in rural areas and in eligible patients who have lower socioeconomic status, limited education, advanced age, and/or female sex14,15 In addition, Gurewich et al16 reported several factors that are likely responsible for the poor referral rates to outpatient CR, which included “the degree of automation and assertiveness in securing referrals, the level of integration of CR within the hospital setting and physician community, the relationship to other CR facilities, and capacity constraints” Given the continually poor referral and participation rate in outpatient CR despite increased efforts to reverse this trend, additional actions are required This scientific advisory calls on the inpatient and home healthcare …

Physician Patient-Sharing Networks and the Cost and Intensity of Care in US Hospitals

Abstract: Background:There is substantial variation in the cost and intensity of care delivered by US hospitals. We assessed how the structure of patient-sharing networks of physicians affiliated with hospitals might contribute to this variation. Methods:We constructed hospital-based professional networks based on patient-sharing ties among 61,461 physicians affiliated with 528 hospitals in 51 hospital referral regions in the US using Medicare data on clinical encounters during 2006. We estimated linear regression models to assess the relationship between measures of hospital network structure and hospital measures of spending and care intensity in the last 2 years of life. Results:The typical physician in an average-sized urban hospital was connected to 187 other doctors for every 100 Medicare patients shared with other doctors. For the average-sized urban hospital an increase of 1 standard deviation (SD) in the median number of connections per physician was associated with a 17.8% increase in total spending, in addition to 17.4% more hospital days, and 23.8% more physician visits (allP< 0.001). In addition, higher “centrality” of primary care providers within these hospital networks was associated with 14.7% fewer medical specialist visits (P< 0.001) and lower spending on imaging and tests (!9.2% and!12.9% for 1 SD increase in centrality,P< 0.001). Conclusions:Hospital-based physician network structure has a significant relationship with an institution’s care patterns for their patients. Hospitals with doctors who have higher numbers of connections have higher costs and more intensive care, and hospitals with primary carecentered networks have lower costs and care intensity.

The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine.

Abstract: To address physician depression and suicide at one U.S. medical school, a faculty committee launched a Suicide Prevention and Depression Awareness Program in 2009 whose focus is medical students’, residents’, and faculty physicians’ mental health. The program consists of a two-pronged approach: (1) screening, assessment, and referral and (2) education. The screening process is anonymous, confidential, and Web based, using customized software created by the American Foundation for Suicide Prevention. The educational component consists of a medical-schoolwide campaign including Grand Rounds on physician burnout, depression, and suicide as well as similar sessions geared toward trainees. The authors document the process of developing and implementing the program, including the program’s origins and goals, their critical decision-making processes, and successes and challenges of the program’s first year. Of the 2,860 medical students, housestaff, and faculty who received the e-mail invitation in the first year, 374 individuals (13%) completed screens, 101/374 (27%) met criteria for significant risk for depression or suicide, and 48/374 (13%) received referrals for mental health evaluation and treatment. The program provided 29 Grand Rounds and other presentations during the first year. This may be the first program that aims to increase awareness of depression and to destigmatize help-seeking in order to prevent suicide and whose target population includes the full panoply of medical school constituents: students, residents, and faculty physicians. The program was well received in its first year, and while demonstrating the prevention of suicides is difficult, the authors are encouraged by the program’s results thus far.

Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature

Abstract: In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.AFTER AN INITIAL REVIEW OF HEALTH TECHNOLOGY ASSESSMENTS AND SYSTEMATIC REVIEWS OF COPD LITERATURE, AND CONSULTATION WITH EXPERTS, MAS IDENTIFIED THE FOLLOWING TOPICS FOR ANALYSIS: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at: http://www.hqontario.ca/en/mas/mas_ohtas_mn.html.Chronic Obstructive Pulmonary Disease (COPD) Evidentiary FrameworkInfluenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisSmoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisCommunity-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisPulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisLong-Term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisNoninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisNoninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisHospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisHome Telehealth for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based AnalysisCost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy ModelEXPERIENCES OF LIVING AND DYING WITH COPD: A Systematic Review and Synthesis of the Qualitative Empirical LiteratureFOR MORE INFORMATION ON THE QUALITATIVE REVIEW, PLEASE CONTACT MITA GIACOMINI AT: http://fhs.mcmaster.ca/ceb/faculty_member_giacomini.htm.FOR MORE INFORMATION ON THE ECONOMIC ANALYSIS, PLEASE VISIT THE PATH WEBSITE: http://www.path-hta.ca/About-Us/Contact-Us.aspx.The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website: http://theta.utoronto.ca/static/contact. OBJECTIVE OF ANALYSIS: The objective of this analysis was to review empirical qualitative research on the experiences of patients with chronic obstructive pulmonary disease (COPD), informal caregivers ("carers"), and health care providers-from the point of diagnosis, through daily living and exacerbation episodes, to the end of life. CLINICAL NEED AND TARGET POPULATION: Qualitative empirical studies (from social sciences, clinical, and related fields) can offer important information about how patients experience their condition. This exploration of the qualitative literature offers insights into patients' perspectives on COPD, their needs, and how interventions might affect their experiences. The experiences of caregivers are also explored. RESEARCH QUESTION: What do patients with COPD, their informal caregivers ("carers"), and health care providers experience over the course of COPD? RESEARCH METHODS: LITERATURE SEARCH: SEARCH STRATEGY: Literature searches for studies published from January 1, 2000, to November 2010 were performed on November 29, 2010, using OVID MEDLINE; on November 26, 2010, using ISI Web of Science; and on November 28, 2010, using EBSCO Cumulative Index to Nursing and Allied Health Literature (CINAHL). Titles and abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. One additional report, highly relevant to the synthesis, appeared in early 2011 during the drafting of this analysis and was included post hoc. INCLUSION CRITERIA: English-language full reports studies published between January 1, 2000, and November 2010primary qualitative empirical research (using any descriptive or interpretive qualitative methodology, including the qualitative component of mixed-methods studies) and secondary syntheses of primary qualitative empirical researchstudies addressing any aspect of the experiences of living or dying with COPD from the perspective of persons at risk, patients, health care providers, or informal carers; studies addressing multiple conditions were included if COPD was addressed explicitly EXCLUSION CRITERIA: studies addressing topics other than the experiences of living or dying with COPD from the perspective of persons at risk, patients, health care providers, or informal carersstudies labelled "qualitative" but not using a qualitative descriptive or interpretive methodology (e.g., case studies, experiments, or observational analysis using qualitative categorical variables)quantitative research (i.e., using statistical hypothesis testing, using primarily quantitative data or analyses, or expressing results in quantitative or statistical terms)studies that did not pose an empirical research objective or question, or involve the primary or secondary analysis of empirical data OUTCOMES OF INTEREST: qualitative descriptions and interpretations (narrative or theoretical) of personal and social experiences of COPD SUMMARY OF FINDINGS: EXPERIENCES AT DIAGNOSIS: Patients typically seek initial treatment for an acute episode rather than for chronic early symptoms of COPD.Many patients initially misunderstand terms such as COPD, chronic obstructive pulmonary disease, or exacerbation.Patients may not realize that COPD is incurable and fatal; some physicians themselves do not consider early COPD to be a fatal disease.Smokers may not readily understand or agree with the idea that smoking caused or worsens their COPD. Those who believe there is a causal link may feel regret or shame. EXPERIENCES OF LIVING DAY TO DAY: COPD patients experience alternating good days and bad days. A roller-coaster pattern of ups and downs becomes apparent, and COPD becomes a way of life.Patients use many means (social, psychological, medical, organizational) to control what they can, and to cope with what they cannot. Economic hardship, comorbidities, language barriers, and low health literacy can make coping more difficult.Increasing vulnerability and unpredictable setbacks make patients dependent on others for practical assistance, but functional limitations, institutional living or self-consciousness can isolate patients from the people they need.For smokers, medical advice to quit can conflict with increased desire to smoke as a coping strategy.Many of the factors that isolate COPD patients from social contact also isolate them from health care. EXPERIENCES OF EXACERBATIONS: Patients may not always attribute repeated exacerbations to advancing disease, instead seeing them as temporary setbacks caused by activities, environmental factors, faltering self-management, or infection.Lack of confidence in community-based services leads some patients to seek hospital admission, but patients also feel vulnerable when hospitalized. They may feel dependent on others for care or traumatized by hospital care routines.Upon hospital discharge following an exacerbation, patients may face new levels of uncertainty about their illness, prognosis, care providers, and supports. EXPERIENCES OF THE END OF LIFE: Patients tend to be poorly informed about the long-term prognosis of COPD and what to expect toward the end of life; this lack of understanding impairs quality of life as the disease progresses.As the end of life approaches, COPD patients face the usual challenges of daily living, but in a context of increasing exacerbations and deepening dependency. Activities and mobility decrease, and life may become confined.Some clinicians have difficulty identifying the beginning of "the end of life," given the unpredictable course of COPD. Long-term physician-patient relationships, familiarity and understanding, trust, good communication skills, sensitivity, and secure discussion settings can help facilitate end-of-life discussions.Divergent meanings and goals of palliative care in COPD lead to confusion about whether such services are the responsibility of home care, primary care, specialty care, or even critical care. Palliative end-of-life care may not be anticipated prior to referral for such care. A palliative care referral can convey the demoralizing message that providers have "given up. (ABSTRACT TRUNCATED)

The role of primary care in service provision for people with severe mental illness in the united kingdom

Abstract: Background Severe mental illness is a serious and potentially life changing set of conditions. This paper describes and analyses patient characteristics and service usage over one year of a representative cohort of people with a diagnosis of severe mental illness across England, including contacts with primary and secondary care and continuity of care. Methods and Findings Data were collected from primary care patient notes (n = 1150) by trained nurses from 64 practices in England, covering all service contacts from 1st April 2008 to 31st March 2009. The estimated national rate of patients seen only in primary care in the period was 31.1% (95% C.I. 27.2% to 35.3%) and the rates of schizophrenia and bipolar disorder were 56.8% (95% C.I. 52.3% to 61.2%) and 37.9% (95% C.I. 33.7% to 42.2%). In total, patients had 7,961 consultations within primary care and 1,993 contacts with mental health services (20% of the total). Unemployed individuals diagnosed more recently were more likely to have contact with secondary care. Of those seen in secondary care, 61% had at most two secondary care contacts in the period. Median annual consultation rates with GPs were lower than have been reported for previous years and were only slightly above the general population. Relational continuity in primary care was poor for 21% of patients (Modified Modified Continuity Index = <0.5), and for almost a third of new referrals to mental health services the primary care record contained no information on the referral outcome. Conclusions Primary care is centrally involved in the care of people with serious mental illness, but primary care and cross-boundary continuity is poor for a substantial proportion. Research is needed to determine the impact of poor continuity on patient outcomes, and above all, the impact of new collaborative ways of working at the primary/secondary care interface.

Leveraging rapid community-based HIV testing campaigns for non-communicable diseases in rural Uganda.

Abstract: BACKGROUND: The high burden of undiagnosed HIV in sub-Saharan Africa limits treatment and prevention efforts. Community-based HIV testing campaigns can address this challenge and provide an untapped opportunity to identify non-communicable diseases (NCDs). We tested the feasibility and diagnostic yield of integrating NCD and communicable diseases into a rapid HIV testing and referral campaign for all residents of a rural Ugandan parish. METHODS: A five-day multi-disease campaign offering diagnostic preventive treatment and referral services was performed in May 2011. Services included point-of-care screening for HIV malaria TB hypertension and diabetes. Finger-prick diagnostics eliminated the need for phlebotomy. HIV-infected adults met clinic staff and peer counselors on-site; those with CD4

The Disproportionality Dilemma: Patterns of Teacher Referrals to School Counselors for Disruptive Behavior.

Abstract: Disproportionality plagues schools nationwide in special education placement, dropout, discipline referral, suspension, and expulsion rates. This study examined predictors of teacher referrals to school counselors for disruptive behavior in a sample of students selected from the Educational Longitudinal Study 2002 (National Center for Education Statistics, n.d.). Findings demonstrated that students’ race predicted English teacher referrals; students’ gender, previous disciplinary infractions, and teachers’ postsecondary expectations for students predicted English and math teacher referrals. Implications for practice, policy, and research are discussed.

The development of a lay health worker delivered collaborative community based intervention for people with schizophrenia in India

Abstract: Background: Care for schizophrenia in low and middle income countries is predominantly facility based and led by specialists, with limited use of non-pharmacological treatments. Although community based psychosocial interventions are emphasised, there is little evidence about their acceptability and feasibility. Furthermore, the shortage of skilled manpower is a major barrier to improving access to these interventions. Our study aimed to develop a lay health worker delivered community based intervention in three sites in India. This paper describes how the intervention was developed systematically, following the MRC framework for the development of complex interventions. Methods: We reviewed the lierature on the burden of schizophrenia and the treatment gap in low and middle income countries and the evidence for community based treatments, and identified intervention components. We then evaluated the acceptability and feasibility of this package of care through formative case studies with individuals with schizophrenia and their primary caregivers and piloted its delivery with 30 families. Results: Based on the reviews, our intervention comprised five components (psycho-education; adherence management; rehabilitation; referral to community agencies; and health promotion) to be delivered by trained lay health workers supervised by specialists. The intervention underwent a number of changes as a result of formative and pilot work. While all the components were acceptable and most were feasible, experiences of stigma and discrimination were inadequately addressed; some participants feared that delivery of care at home would lead to illness disclosure; some participants and providers did not understand how the intervention related to usual care; some families were unwilling to participate; and there were delivery problems, for example, in meeting the targeted number of sessions. Participants found delivery by health workers acceptable, and expected them to have knowledge about the subject matter. Some had expectations regarding their demographic and personal characteristics, for example, preferring only females or those who are understanding/friendly. New components to address stigma were then added to the intervention, the collaborative nature of service provision was strengthened, a multi-level supervision system was developed, and delivery of components was made more flexible. Criteria were evolved for the selection and training of the health workers based on participants’ expectations.

Global perspective on early diagnosis and intervention for children with developmental delays and disabilities

Abstract: Low- and middle-income countries are experiencing a significant reduction in mortality of children under 5 years of age. This reduction is bringing in its wake large numbers of surviving children with developmental delays and disabilities. Very little attention has been paid to these children, most of whom receive minimal or no support. Thus, there is an urgent need to recognize that improving the quality of life of the survivors must complement mortality reduction in healthcare practice and programs. The incorporation of early evaluation and intervention programs into routine pediatric care is likely to have the most impact on the quality of life of these children. We therefore call for leadership from practitioners, governments, and international organizations to prioritize regular childhood developmental surveillance for possible delays and disabilities, and to pursue early referral for intervention.

The Effectiveness of Emergency Obstetric Referral Interventions in Developing Country Settings: A Systematic Review

Abstract: Background Pregnancy complications can be unpredictable and many women in developing countries cannot access health facilities where life-saving care is available. This study assesses the effects of referral interventions that enable pregnant women to reach health facilities during an emergency, after the decision to seek care is made. Methods and findings Selected bibliographic databases were searched with no date or language restrictions. Randomised controlled trials and quasi experimental study designs with a comparison group were included. Outcomes of interest included maternal and neonatal mortality and other intermediate measures such as service utilisation. Two reviewers independently selected, appraised, and extracted articles using predefined fields. Forest plots, tables, and qualitative summaries of study quality, size, and direction of effect were used for analysis. Nineteen studies were included. In South Asian settings, four studies of organisational interventions in communities that generated funds for transport reduced neonatal deaths, with the largest effect seen in India (odds ratio 0·48 95% CI 0·34–0·68). Three quasi experimental studies from sub-Saharan Africa reported reductions in stillbirths with maternity waiting home interventions, with one statistically significant result (OR 0.56 95% CI 0.32–0.96). Effects of interventions on maternal mortality were unclear. Referral interventions usually improved utilisation of health services but the opposite effect was also documented. The effects of multiple interventions in the studies could not be disentangled. Explanatory mechanisms through which the interventions worked could not be ascertained. Conclusions Community mobilisation interventions may reduce neonatal mortality but the contribution of referral components cannot be ascertained. The reduction in stillbirth rates resulting from maternity waiting homes needs further study. Referral interventions can have unexpected adverse effects. To inform the implementation of effective referral interventions, improved monitoring and evaluation practices are necessary, along with studies that develop better understanding of how interventions work. Please see later in the article for the Editors' Summary

Conceptual models for integrating palliative care at cancer centers.

Abstract: Palliative care programs are rapidly evolving in acute care facilities. Increased and earlier access has been advocated for patients with life-threatening illnesses. Existing programs would need major growth to accommodate the increased utilization. The objective of this review is to provide an update on the current structures, processes, and outcomes of the Supportive and Palliative Care Program at the University of Texas M.D. Anderson Cancer Center (UTMDACC), and to use the update as a platform to discuss the challenges and opportunities in integrating palliative and supportive services in a tertiary care cancer center. Our interprofessional program consists of a mobile consultation team, an acute palliative care unit, and an outpatient supportive care clinic. We will discuss various metrics including symptom outcomes, quality of end-of-life care, program growth, and financial issues. Despite the growing evidence to support early palliative care involvement, referral to palliative care remains ...

Unplanned pregnancy and contraceptive use in women attending drug treatment services.

Abstract: BACKGROUND: At an international level there are calls for a greater focus on women and harm reduction in recognition that female drug users have a unique set of issues that are not routinely assessed in drug treatment programs. AIMS: To assess the pregnancy history current pregnancy risk and contraceptive use of nonpregnant women attending opioid treatment programs (OTPs). METHODS: This study involved a structured questionnaire survey of 204 women attending outpatient OTP services within the Sydney South West Area Health Service. RESULTS: Two hundred and four women of 302 (67.5%) enroled in OTPs at the time completed surveys. Key findings were high pregnancy rates with 28.9% of women reporting six or more pregnancies high rates of adverse pregnancy outcomes (miscarriage termination and stillbirth) compared with national data and poor uptake of contraception with only 54.7% of sexually active women not wanting to get pregnant using a method. Women expressed diverse preferences for the type and location of womens health services they felt would meet their needs. CONCLUSION: Women in OTP clinics have unaddressed reproductive health issues particularly around contraception. Addressing these will potentially minimise the risk of material deprivation and social exclusion in these women and improve their well-being through greater control and choice over their fertility. Current womens health service provision in OTP programs involves referral to external services but an integrated model of care may best address the unmet contraceptive needs of these women. (c) 2012 The Authors ANZJOG (c) 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Strategies for improving perinatal depression treatment in North American outpatient obstetric settings

Abstract: Objective: To identify core barriers and facilitators to addressing perinatal depression and review clinical, programmatic, and system level interventions that may optimize perinatal depression treatment. Method: Eighty-four MEDLINE/PubMed searches were conducted using the terms perinatal depression, postpartum depression, antenatal depression, and prenatal depression in association with 21 other terms. Of 7768 papers yielded in the search, we identified 49 papers on barriers and facilitators, and 17 papers on interventions in obstetric settings aimed to engage women and/or providers in treatment. Results: Barriers include stigma, lack of obstetric provider training, lack of resources and limited access to mental health treatment. Facilitators include validating and empowering women during interactions with health care providers, obstetric provider and staff training, standardized screening and referral processes, and improved mental health resources. Conclusion: Specific clinical, program, and system level changes are recommended to help change the culture of obstetric care settings to optimize depression treatment.

Referral and final diagnoses of patients assessed in an academic vertigo center

Abstract: OBJECTIVE: To identify under-diagnosed neuro-otological disorders and to evaluate whether under-diagnosing depends on the age of the patient. MATERIAL AND METHODS: Retrospective analysis of medical charts from 951 consecutive patients (685 under and 266 above the age of 65 years) who entered diagnostic procedures at the Interdisciplinary Center for Vertigo and Balance Disorders, University Hospital Zurich, Switzerland. Final diagnoses were compared to referral diagnoses. RESULTS: Relative to referral diagnoses, the proportion of patients finally diagnosed with benign paroxysmal positional vertigo (BPPV) almost doubled both in younger (< 65 year from 12.7% to 25.1%) and older patients (from 20.7% to 37.6%). Striking relative increases were found for the diagnoses multisensory dizziness in older patients (from 20.7% to 37.6%) and vestibular migraine in younger patients (1.8% to 20.2%). In both age groups, the proportion of patients with undetermined diagnoses was reduced by about 60% (younger: 69.8% to 9.8%; older: 69.2% to 12.4%) by the diagnostic procedures in the vertigo center. These changes were all significant (p < 0.05) in McNemar tests with continuity correction (2x2 tables: focused diagnosis vs. other diagnoses, referral vs. final). CONCLUSION: Significant changes of diagnoses can be expected by a specialized neuro-otological work-up. In particular, BPPV, multisensory dizziness, and vestibular migraine are under-diagnosed by referring physicians. This finding calls for better education of primary care takers in the field of neuro-otology.

Early diagnosis of lung cancer: evaluation of a community-based social marketing intervention

Abstract: Background Poor UK lung cancer survival rates may, in part, be due to late diagnosis. Objectives To evaluate the effectiveness of a mixedmethod community-based social marketing intervention on lung cancer diagnoses. Methods A public awareness campaign in conjunction with brief intervention training in general practices was piloted in six localities with a high lung cancer incidence. End points were self-reported awareness of lung cancer symptoms; intention to seek healthcare; chest x-ray referral rates in primary care; secular trends in the incidence of lung cancer and stage at diagnosis, compared before and after the intervention. Results 21% (128/600) (95% CI 18% to 25%) of the targeted population recalled something about the campaign. Compared with a responder in the control area, the odds of a responder in the intervention area saying that they would visit their general practitioner and request a chest x-ray for a cough was 1.97 times (95% CI 1.18 to 3.31, p¼0.01). Primary care chest x-ray referral rates increased by 20% in the targeted practices in the year following the intervention compared with a 2% fall in the control practices. The difference was highly significant, with an incidence rate ratio of 1.22 (95% CI 1.12 to 1.33, p¼0.001). There was a 27% increase in lung cancer diagnoses in the intervention area compared with a fall in the control area. The incidence rate ratio was 1.42 (95% CI 0.83 to 2.44 p¼0.199). Conclusion This is encouraging early evidence that an awareness and early recognition initiative may facilitate lung cancer diagnosis.

Health Supervision in the Management of Children and Adolescents With IBD: NASPGHAN Recommendations

Abstract: Ulcerative colitis (UC) and Crohn disease (CD), collectively referred to as inflammatory bowel disease (IBD), are chronic inflammatory disorders that can affect the gastrointestinal tract of children and adults. Like other autoimmune processes, the cause(s) of these disorders remain unknown but likely involves some interplay between genetic vulnerability and environmental factors. Children, in particular with UC or CD, can present to their primary care providers with similar symptoms, including abdominal pain, diarrhea, weight loss, and bloody stool. Although UC and CD are more predominant in adults, epidemiologic studies have demonstrated that a significant percentage of these patients were diagnosed during childhood. The chronic nature of the inflammatory process observed in these children and the waxing and waning nature of their clinical symptoms can be especially disruptive to their physical, social, and academic development. As such, physicians caring for children must consider these diseases when evaluating patients with compatible symptoms. Recent research efforts have made available a variety of more specific and effective pharmacologic agents and improved endoscopic and radiologic assessment tools to assist clinicians in the diagnosis and interval assessment of their patients with IBD; however, as the level of complexity of these interventions has increased, so too has the need for practitioners to become familiar with a wider array of treatments and the risks and benefits of particular diagnostic testing. Nonetheless, in most cases, and especially when frequent visits to subspecialty referral centers are not geographically feasible, primary care providers can be active participants in the management of their pediatric patients with IBD. The goal of this article is to educate and assist pediatricians and adult gastroenterology physicians caring for children with IBD, and in doing so, help to develop more collaborative care plans between primary care and subspecialty providers.

Common mental health disorders — identification and pathways to care: NICE clinical guideline

Abstract: NICE has developed a guideline on the identification of common mental health disorders (CMHDs) and on pathways to care for these disorders.1 These CMHDs include: The prevalence of CMHDs in the community is around 15%, and even higher, around 20%, among people attending general practice. The costs of CMHDs are high. They are estimated to cause 1 in 5 days lost from work in Britain.2 There are problems with access to care and with identification of people with CMHDs. In the 2007 household survey of adult psychiatric morbidity only 38% of people with CMHDs had asked their GP for help, and only 24% were receiving treatment (14% medication; 5% counselling; and 5% both).3 The aim of the NICE guideline is to improve access to services, improve the recognition and identification of CMHDs, and provide advice on developing care pathways. There is a need for greater clarity around the indications for treatment and referral of CMHDs, including severity, duration, associated disability, and other factors likely to affect responses to drug and psychological treatments. A more systematic approach to organising care pathways is needed, including the consideration of developing ‘stepped care’ systems and ‘collaborative care’ across the primary and secondary care sectors of the NHS. The guideline also brings together in one place advice from existing NICE guidelines on referral for and treatment of the disorders. These are guidelines on depression in adults,4 depression with chronic physical health problems,5 GAD and panic disorder,6 antenatal and postnatal mental health,7 OCD,8 and PTSD.9 The individual guidelines already developed cover treatment, but vary in their coverage of identification, assessment, and appropriate referral. ### Identification The guideline states that practitioners should be …