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Showing papers on "Referral published in 2015"


Journal ArticleDOI
TL;DR: Systematically screening and referring for social determinants during well child care can lead to the receipt of more community resources for families.
Abstract: OBJECTIVE: To evaluate the effect of a clinic-based screening and referral system (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education [WE CARE]) on families’ receipt of community-based resources for unmet basic needs. METHODS: We conducted a cluster randomized controlled trial at 8 urban community health centers, recruiting mothers of healthy infants. In the 4 WE CARE clinics, mothers completed a self-report screening instrument that assessed needs for child care, education, employment, food security, household heat, and housing. Providers made referrals for families; staff provided requisite applications and telephoned referred mothers within 1 month. Families at the 4 control community health centers received the usual care. We analyzed the results with generalized mixed-effect models. RESULTS: Three hundred thirty-six mothers were enrolled in the study (168 per arm). The majority of families had household incomes CONCLUSIONS: Systematically screening and referring for social determinants during well child care can lead to the receipt of more community resources for families.

431 citations


Journal ArticleDOI
TL;DR: The purpose of this practice guideline is to present a single set of comprehensive personal and family history criteria to facilitate identification and maximize appropriate referral of at-risk individuals for cancer genetic consultation.

393 citations


Journal ArticleDOI
TL;DR: The overall quality of the body of evidence was low to moderate, mainly due to heterogeneity, risk of bias, and imprecision; the majority of studies minimised selection bias; performance bias was the greatest threat to validity.
Abstract: BACKGROUND: Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for IPV rather than asking only women with symptoms (case-finding). Here, we examine the evidence for whether screening benefits women and has no deleterious effects. OBJECTIVES: To assess the effectiveness of screening for IPV conducted within healthcare settings on identification, referral, re-exposure to violence, and health outcomes for women, and to determine if screening causes any harm. SEARCH METHODS: On 17 February 2015, we searched CENTRAL, Ovid MEDLINE, Embase, CINAHL, six other databases, and two trial registers. We also searched the reference lists of included articles and the websites of relevant organisations. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials assessing the effectiveness of IPV screening where healthcare professionals either directly screened women face-to-face or were informed of the results of screening questionnaires, as compared with usual care (which could include screening that did not involve a healthcare professional). DATA COLLECTION AND ANALYSIS: Two authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the odds ratio (OR). For continuous data, either a mean difference (MD) or standardised mean difference (SMD) was calculated. All are presented with a 95% confidence interval (CI). MAIN RESULTS: We included 13 trials that recruited 14,959 women from diverse healthcare settings (antenatal clinics, women's health clinics, emergency departments, primary care) predominantly located in high-income countries and urban settings. The majority of studies minimised selection bias; performance bias was the greatest threat to validity. The overall quality of the body of evidence was low to moderate, mainly due to heterogeneity, risk of bias, and imprecision.We excluded five of 13 studies from the primary analysis as they either did not report identification data, or the way in which they did was not consistent with clinical identification by healthcare providers. In the remaining eight studies (n = 10,074), screening increased clinical identification of victims/survivors (OR 2.95, 95% CI 1.79 to 4.87, moderate quality evidence).Subgroup analyses suggested increases in identification in antenatal care (OR 4.53, 95% CI 1.82 to 11.27, two studies, n = 663, moderate quality evidence); maternal health services (OR 2.36, 95% CI 1.14 to 4.87, one study, n = 829, moderate quality evidence); and emergency departments (OR 2.72, 95% CI 1.03 to 7.19, three studies, n = 2608, moderate quality evidence); but not in hospital-based primary care (OR 1.53, 95% CI 0.79 to 2.94, one study, n = 293, moderate quality evidence).Only two studies (n = 1298) measured referrals to domestic violence support services following clinical identification. We detected no evidence of an effect on referrals (OR 2.24, 95% CI 0.64 to 7.86, low quality evidence).Four of 13 studies (n = 2765) investigated prevalence (excluded from main analysis as rates were not clinically recorded); detection of IPV did not differ between face-to-face screening and computer/written-based assessment (OR 1.12, 95% CI 0.53 to 2.36, moderate quality evidence).Only two studies measured women's experience of violence (three to 18 months after screening) and found no evidence that screening decreased IPV.Only one study reported on women's health with no differences observable at 18 months.Although no study reported adverse effects from screening interventions, harm outcomes were only measured immediately afterwards and only one study reported outcomes at three months.There was insufficient evidence on which to judge whether screening increases uptake of specialist services, and no studies included an economic evaluation. AUTHORS' CONCLUSIONS: The evidence shows that screening increases the identification of women experiencing IPV in healthcare settings. Overall, however, rates were low relative to best estimates of prevalence of IPV in women seeking healthcare. Pregnant women in antenatal settings may be more likely to disclose IPV when screened, however, rigorous research is needed to confirm this. There was no evidence of an effect for other outcomes (referral, re-exposure to violence, health measures, lack of harm arising from screening). Thus, while screening increases identification, there is insufficient evidence to justify screening in healthcare settings. Furthermore, there remains a need for studies comparing universal screening to case-finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing in order to inform IPV identification policies in healthcare settings. Language: en

384 citations


Journal ArticleDOI
TL;DR: The findings in this study extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system.
Abstract: Initial management decisions following a new episode of low back pain (LBP) are thought to have profound implications for health care utilization and costs. The purpose of this study was to evaluate the impact of early and guideline adherent physical therapy for low back pain on utilization and costs within the Military Health System (MHS). Patients presenting to a primary care setting with a new complaint of LBP from January 1, 2007 to December 31, 2009 were identified from the MHS Management Analysis and Reporting Tool. Descriptive statistics, utilization, and costs were examined on the basis of timing of referral to physical therapy and adherence to practice guidelines over a 2-year period. Utilization outcomes (advanced imaging, lumbar injections or surgery, and opioid use) were compared using adjusted odds ratios with 99% confidence intervals. Total LBP-related health care costs over the 2-year follow-up were compared using linear regression models. 753,450 eligible patients with a primary care visit for LBP between 18–60 years of age were considered. Physical therapy was utilized by 16.3% (n = 122,723) of patients, with 24.0% (n = 17,175) of those receiving early physical therapy that was adherent to recommendations for active treatment. Early referral to guideline adherent physical therapy was associated with significantly lower utilization for all outcomes and 60% lower total LBP-related costs. The potential for cost savings in the MHS from early guideline adherent physical therapy may be substantial. These results also extend the findings from similar studies in civilian settings by demonstrating an association between early guideline adherent care and utilization and costs in a single payer health system. Future research is necessary to examine which patients with LBP benefit early physical therapy and determine strategies for providing early guideline adherent care.

184 citations


Journal ArticleDOI
TL;DR: Transportation barriers in health access in a rural context based on perceived cause, coping mechanisms and strategies for a sustainable transportation system underscore the need for policy to address rural transport problems in order to improve maternal health.
Abstract: The Ghana Community based Health Planning and Services (CHPS) strategy targets to bring health services to the doorsteps of clients in a manner that improves maternal and child health outcomes. In this strategy, referral is an important component but it is threatened in a rural context where transportation service is a problem. Few studies have examined perceptions of rural dwellers on transportation challenges in accessing maternal health care services within CHPS. Using the political ecology of health framework, this paper investigates transportation barriers in health access in a rural context based on perceived cause, coping mechanisms and strategies for a sustainable transportation system. Eight (8) focus group discussions involving males (n = 40) and females (n = 45) in rural communities in a CHPS zone in the Upper West Region of Ghana were conducted between September and December 2013. Lack of vehicular transport is suppressing the potential positive impact of CHPS on maternal and child health. Consistent neglect of road infrastructural development and endemic poverty in the study area makes provision of alternative transport services for health care difficult. As a result, pregnant women use risky methods such as bicycle/tricycle/motorbikes to access obstetric health care services, and some turn to traditional medicines and traditional birth attendants for maternal health care services. These findings underscore the need for policy to address rural transport problems in order to improve maternal health. Community based transport strategy with CHPS is proposed to improve adherence to referral and access to emergency obstetric services.

165 citations


Journal ArticleDOI
TL;DR: The views, experiences, and behaviours of skilled birth attendants and those who support them were explored to identify factors that influence the delivery of intrapartum and postnatal care in low‐ and middle‐income countries; and the extent to which these factors were reflected in intervention studies was explored.
Abstract: Background In many low- and middle-income countries women are encouraged to give birth in clinics and hospitals so that they can receive care from skilled birth attendants. A skilled birth attendant (SBA) is a health worker such as a midwife, doctor, or nurse who is trained to manage normal pregnancy and childbirth. (S)he is also trained to identify, manage, and refer any health problems that arise for mother and baby. The skills, attitudes and behaviour of SBAs, and the extent to which they work in an enabling working environment, impact on the quality of care provided. If any of these factors are missing, mothers and babies are likely to receive suboptimal care. Objectives To explore the views, experiences, and behaviours of skilled birth attendants and those who support them; to identify factors that influence the delivery of intrapartum and postnatal care in low- and middle-income countries; and to explore the extent to which these factors were reflected in intervention studies. Search methods Our search strategies specified key and free text terms related to the perinatal period, and the health provider, and included methodological filters for qualitative evidence syntheses and for low- and middle-income countries. We searched MEDLINE, OvidSP (searched 21 November 2016), Embase, OvidSP (searched 28 November 2016), PsycINFO, OvidSP (searched 30 November 2016), POPLINE, K4Health (searched 30 November 2016), CINAHL, EBSCOhost (searched 30 November 2016), ProQuest Dissertations and Theses (searched 15 August 2013), Web of Science (searched 1 December 2016), World Health Organization Reproductive Health Library (searched 16 August 2013), and World Health Organization Global Health Library for WHO databases (searched 1 December 2016). Selection criteria We included qualitative studies that focused on the views, experiences, and behaviours of SBAs and those who work with them as part of the team. We included studies from all levels of health care in low- and middle-income countries. Data collection and analysis One review author extracted data and assessed study quality, and another review author checked the data. We synthesised data using the best fit framework synthesis approach and assessed confidence in the evidence using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. We used a matrix approach to explore whether the factors identified by health workers in our synthesis as important for providing maternity care were reflected in the interventions evaluated in the studies in a related intervention review. Main results We included 31 studies that explored the views and experiences of different types of SBAs, including doctors, midwives, nurses, auxiliary nurses and their managers. The included studies took place in Africa, Asia, and Latin America. Our synthesis pointed to a number of factors affecting SBAs’ provision of quality care. The following factors were based on evidence assessed as of moderate to high confidence. Skilled birth attendants reported that they were not always given sufficient training during their education or after they had begun clinical work. Also, inadequate staffing of facilities could increase the workloads of skilled birth attendants, make it difficult to provide supervision and result in mothers being offered poorer care. In addition, SBAs did not always believe that their salaries and benefits reflected their tasks and responsibilities and the personal risks they undertook. Together with poor living and working conditions, these issues were seen to increase stress and to negatively affect family life. Some SBAs also felt that managers lacked capacity and skills, and felt unsupported when their workplace concerns were not addressed. Possible causes of staff shortages in facilities included problems with hiring and assigning health workers to facilities where they were needed; lack of funding; poor management and bureaucratic systems; and low salaries. Skilled birth attendants and their managers suggested factors that could help recruit, keep, and motivate health workers, and improve the quality of care; these included good-quality housing, allowances for extra work, paid vacations, continuing education, appropriate assessments of their work, and rewards. Skilled birth attendants’ ability to provide quality care was also limited by a lack of equipment, supplies, and drugs; blood and the infrastructure to manage blood transfusions; electricity and water supplies; and adequate space and amenities on maternity wards. These factors were seen to reduce SBAs’ morale, increase their workload and infection risk, and make them less efficient in their work. A lack of transport sometimes made it difficult for SBAs to refer women on to higher levels of care. In addition, women’s negative perceptions of the health system could make them reluctant to accept referral. We identified some other factors that also may have affected the quality of care, which were based on findings assessed as of low or very low confidence. Poor teamwork and lack of trust and collaboration between health workers appeared to negatively influence care. In contrast, good collaboration and teamwork appeared to increase skilled birth attendants’ motivation, their decision-making abilities, and the quality of care. Skilled birth attendants’ workloads and staff shortages influenced their interactions with mothers. In addition, poor communication undermined trust between skilled birth attendants and mothers. Authors' conclusions Many factors influence the care that SBAs are able to provide to mothers during childbirth. These include access to training and supervision; staff numbers and workloads; salaries and living conditions; and access to well-equipped, well-organised healthcare facilities with water, electricity, and transport. Other factors that may play a role include the existence of teamwork and of trust, collaboration, and communication between health workers and with mothers. Skilled birth attendants reported many problems tied to all of these factors.

150 citations


Journal ArticleDOI
TL;DR: The high proportions of young people lost to follow-up and experienced long gaps in care after leaving pediatric cardiology highlight the need for formal transition programs, which ensure a planned and coordinated transfer.
Abstract: This review synthesizes the empirical literature on outcomes and experiences of transfer and transition from pediatric to adult care for young people with congenital heart disease. A systematic review of papers published between January 2001 and May 2013 that examined outcomes or experiences of transfer and transition among young people with congenital heart disease was conducted. Data were extracted by two independent reviewers with the outcomes data combined using narrative synthesis and the experiences data integrated using thematic synthesis. Thirteen papers were included in the review: six reported outcomes following transfer, six reported experiences of transfer and transition, and one reported both outcomes and experiences. The review data indicate that high proportions of young people were lost to follow-up or experienced long gaps in care after leaving pediatric cardiology. Factors that protected against loss to follow-up or lapse in care included: beliefs that specialized adult care was necessary; poorer health status; attendance at pediatric appointments without parents; and pediatric referral to an adult congenital heart disease center. Data on experiences highlighted that many young people were unconcerned about transition, but lacked knowledge about their condition and were insufficiently prepared for transfer. In terms of adult services, many young people desired continuity in the quality of care, youth-oriented facilities, a personalized approach, and for their parents to remain involved in their care, but in a secondary, supportive capacity. In conclusion, the high proportions of young people lost to follow-up highlight the need for formal transition programs, which ensure a planned and coordinated transfer. Patients with congenital heart disease need education throughout adolescence about the implications of their condition, the differences between pediatric and adult services, and self-care management.

149 citations


Journal ArticleDOI
TL;DR: Evidence-based interventions to increase referral for all patients, including women, need to be instituted to ensure broader implementation of sex differences in referral rates, which are significantly lower for women than men.
Abstract: BackgroundCardiovascular disease continues to be among the leading causes of morbidity and mortality among men and women globally. However, research suggests that women are significantly underrepre...

149 citations


Journal ArticleDOI
TL;DR: Compared with patients discharged without CR referral, patients referred for CR were younger, predominantly men, and more likely to receive evidence-based HF therapies at discharge, and younger age, fewer comorbid conditions, and in-hospital procedures were most strongly associated with CR referral.

142 citations


Journal ArticleDOI
TL;DR: Research on access to genetic services is heterogeneous; stronger empirical evidence is needed on factors that are barriers, and further research is needed to develop ‘targeted interventions’ for equitable access to Genetic services in a range of populations.
Abstract: Patients who might benefit from genetic services may be denied access through failure to be referred. To investigate the evidence on barriers to referral to genetic services, we conducted a systematic review of empirical evidence on this topic. Nine studies were included in the review. Barriers related to non-genetic healthcare professionals were: lack of awareness of patient risk factors, failure to obtain adequate family history, lack of knowledge of genetics and genetic conditions, lack of awareness of genetic services, inadequate coordination of referral and lack of genetics workforce. Those related to individuals affected by or at risk of a genetic condition were: lack of awareness of personal risk, lack of knowledge and/or awareness of medical history of family members and lack of knowledge of genetic services. Research on access to genetic services is heterogeneous; stronger empirical evidence is needed on factors that are barriers, and further research is needed to develop 'targeted interventions' for equitable access to genetic services in a range of populations.

130 citations


Journal ArticleDOI
TL;DR: Key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery are identified and initiatives to improve quality of client-provider interaction and respect for women are essential.
Abstract: Thousands of women and newborns still die preventable deaths from pregnancy and childbirth-related complications in poor settings. Delivery with a skilled birth attendant is a vital intervention for saving lives. Yet many women, particularly where maternal mortality ratios are highest, do not have a skilled birth attendant at delivery. In Uganda, only 58 % of women deliver in a health facility, despite approximately 95 % of women attending antenatal care (ANC). This study aimed to (1) identify key factors underlying the gap between high rates of antenatal care attendance and much lower rates of health-facility delivery; (2) examine the association between advice during antenatal care to deliver at a health facility and actual place of delivery; (3) investigate whether antenatal care services in a post-conflict district of Northern Uganda actively link women to skilled birth attendant services; and (4) make recommendations for policy- and program-relevant implementation research to enhance use of skilled birth attendance services. This study was carried out in Gulu District in 2009. Quantitative and qualitative methods used included: structured antenatal care client entry and exit interviews [n = 139]; semi-structured interviews with women in their homes [n = 36], with health workers [n = 10], and with policymakers [n = 10]; and focus group discussions with women [n = 20], men [n = 20], and traditional birth attendants [n = 20]. Seventy-five percent of antenatal care clients currently pregnant reported they received advice during their last pregnancy to deliver in a health facility, and 58 % of these reported having delivered in a health facility. After adjustment for confounding, women who reported they received advice at antenatal care to deliver at a health facility were significantly more likely (aOR = 2.83 [95 % CI: 1.19–6.75], p = 0.02) to report giving birth in a facility. Despite high antenatal care coverage, a number of demand and supply side barriers deter use of skilled birth attendance services. Primary barriers were: fear of being neglected or maltreated by health workers; long distance and other difficulties in access; poverty, and material requirements for delivery; lack of support from husband/partner; health systems deficiencies such as inadequate staffing/training, work environment, and referral systems; and socio-cultural and gender issues such as preferred birthing position and preference for traditional birth attendants. Initiatives to improve quality of client-provider interaction and respect for women are essential. Financial barriers must be abolished and emergency transport for referrals improved. Simultaneously, supply-side barriers must be addressed, notably ensuring a sufficient number of health workers providing skilled obstetric care in health facilities and creating habitable conditions and enabling environments for them.

Journal ArticleDOI
TL;DR: There are multiple conceptual models and clinical models to promote integration of oncology and palliative care, and further research is needed to inform best practices for integration at different healthcare settings.
Abstract: Main problem: Palliative care aims to improve cancer patients’ quality of life through expert symptom management, psychosocial and spiritual care, patient-clinician communication, facilitation of complex decision making, and end-of-life care planning. Over the past few years, there has been increasing interest and evidence to support integration of oncology and palliative care. However, it remains unclear how best to promote integration. The goal of this review is to examine contemporary conceptual models and clinical approaches to integrate oncology and palliative care. Methods: Narrative review. Results: Conceptual models are useful to help stakeholders understand the rationale for integration, to compare the risks and benefits among different practices, and to define a vision towards integration. We will review four major conceptual models of integration, including (I) the time-based model which emphasizes on integration based on chronological criterion; (II) the provider-based (palli-centric) model which discusses primary, secondary and tertiary palliative care; (III) the issue-based (onco-centric) model which illustrates the advantages and disadvantages of the solo practice, congress and integrated care approaches, and (IV) the system-based (patient-centric) model which emphasizes automatic referral based on clinical events. Clinical models provide actual data on the feasibility, efficacy and effectiveness of integration in specific settings. The evidence and challenges related to selected clinical models in integrating oncology and palliative care, such as outpatient palliative care clinics and embedded clinics will be discussed. Conclusions: There are multiple conceptual models and clinical models to promote integration. Further research is needed to inform best practices for integration at different healthcare settings.

Journal ArticleDOI
01 Feb 2015-Chest
TL;DR: The majority of patients with IPF died in a hospital setting and only a minority received a formal palliative care referral, indicating the need to study adequacy of end-of-life management in IPF and promote earlier discussion and referral to palliatives care.

Posted Content
TL;DR: In this paper, the authors investigate the effect of personalization and scarcity on consumer referral behavior in an online fashion service named StyleCrowd and find that personalization cues are particularly effective when scarcity is absent, while scarcity is prevalent.
Abstract: Against the backdrop of consumers being deluged with traditional online advertising, which is increasingly manifesting in inefficient conversion outcomes, viral marketing has become a pivotal component of marketing strategy. However, despite a robust understanding about the impact of viral marketing as well as of factors that drive consumer referral engagement, we know very little about the effect of traditional promotional tactics on consumer referral decisions. Drawing on a randomized field experiment in the context of an online fashion service named StyleCrowd, we investigate the effects of scarcity and personalization, two classical promotional cues that have become ubiquitous on the web and have received only minimal attention hitherto, on actual referral behavior. Our analysis reveals that using these cues in promotional campaigns is a balancing act: While scarcity cues affect referral propensity regardless of whether a campaign is personalized or not, personalization cues are particularly effective when scarcity is absent, yet are cancelled out when scarcity is prevalent. We demonstrate that consumers' perceptions of offer value drive the impact of scarcity on referral likelihood, while consumer gratitude vis-a-vis the marketer is the underlying mechanism for personalization's influence on referral decisions.

Journal ArticleDOI
TL;DR: Findings highlight the potential need for hospital-level interventions to improve cardiac rehabilitation referral rates after PCI and suggest site-specific variation in referral rates is significant and is unexplained by insurance coverage.

Journal ArticleDOI
TL;DR: This is the first large cohort study to demonstrate that referral to and attendance at CR is associated with a significant mortality reduction in women, comparatively better than that in men.
Abstract: BackgroundCardiac rehabilitation (CR) reduces mortality in women and men with coronary artery disease (CAD). The objective of this study was to examine sex differences in long-term mortality, based...

Journal ArticleDOI
01 Jul 2015-Chest
TL;DR: Critically ill patients generally benefit from care in high-volume centers, with more substantial benefits in selected high-risk conditions, and this relationship may in part be mediated by specific ICU and hospital organizational factors.

Journal ArticleDOI
TL;DR: It is argued that an integrated clinical-research program based on specialized EI guidelines can significantly improve outcomes and advance FEP research.
Abstract: This paper provides an overview of early intervention (EI) services for psychosis in Canada. We describe a leading Canadian EI program’s approach to enhancing access (via early case detection, open referral, and rapid response) and providing specialized phase-specific treatment. Learnings fr

Journal ArticleDOI
Clare Liddy1, Amir Afkham1, Paul Drosinis1, Justin Joschko1, Erin Keely1 
TL;DR: The results illustrate the advantages of using asynchronous virtual platforms to increase access to specialty care from a PCP perspective and show a high level of satisfaction with eConsult's quick turnaround time and quality of specialist advice.
Abstract: Objectives: We have improved access to specialist care and decreased wait times in our region through the development and implementation of the Champlain BASE (Building Access to Specialists through eConsultation) service. This secure, web-based tool allows primary care providers (PCPs) quick access to specialist advice for their patients and often helps to avoid the need for a face-to-face referral. Our successful implementation of eConsult in our region provides a unique opportunity to examine PCPs9 satisfaction and overall perspective on using the service. Methods: Following the closure of each case, PCPs completed a short survey with multiple-choice and open-ended questions regarding the eConsult. All eConsults submitted between April 15, 2011, and December 31, 2013, were analyzed. We calculated satisfaction scores from the survey and conducted a constant-comparison thematic analysis on those cases where the PCP elected to leave a text response. Results: We analyzed 2,052 eConsults completed during the study period. In 91% and 93% of eConsults, PCPs reported a high value for their patients and themselves, respectively. In 554 eConsults, PCPs elected to leave a written response. Three major themes emerged: PCP appreciation of the eConsult service, perceived benefits for the quality of patient care, and attitudes towards using a new health technology. High satisfaction was expressed with quick response times, helpfulness of responses, and reassurance reported. Most PCPs felt eConsult had a positive impact on patient care by also providing reassurance to patients, reducing burden of time and travel, and offering educational opportunities to PCPs applicable to future cases. Conclusion: PCPs showed a high level of satisfaction with eConsult9s quick turnaround time and quality of specialist advice. Our results illustrate the advantages of using asynchronous virtual platforms to increase access to specialty care from a PCP perspective.

Journal ArticleDOI
TL;DR: Systematic tracking of distress screening protocols is needed to demonstrate compliance with new standards of care and to demonstrate how well institutions are responding to their clinical obligation to address cancer patients' emotional and psychosocial needs.
Abstract: Purpose The American College of Surgeons Commission on Cancer has mandated implementation of a systematic protocol for psychosocial distress screening and referral as a condition for cancer center accreditation beginning in 2015. Compliance with standards requires evidence that distress screening protocols are carried out as intended and result in appropriate referral and follow-up when indicated. The purpose of this study was to examine the fidelity of distress screening protocols at two tertiary cancer treatment centers. Methods A retrospective review and analysis of electronic medical records over a 12-week period examined clinic adherence to a prescribed distress screening protocol and responsiveness to patients whose scores on the National Comprehensive Cancer Network Distress Thermometer (DT) indicated clinically significant levels of distress requiring subsequent psychosocial contact. A weekly online survey assessed clinician perspectives on the acceptability of the protocol. Results Across clinics...

Journal ArticleDOI
TL;DR: Routine screening and assessment of both parents should occur across the pregnancy and postnatal period, and the use of the Edinburgh Postnatal Depression Scale needs to be linked to referral guidelines for those individuals who require further investigation and care.
Abstract: The aim of this project was to review current research regarding postnatal depression in fathers and to present potential screening and referral options. The search was limited to scholarly (peer reviewed) journals and all articles were retrieved with date limits. Initial search parameters were the following: antenatal depression OR pregnancy depression OR postnatal depression OR perinatal depression AND father* OR men OR paternal. The search yielded 311 abstracts returned. With reference to the inclusion criteria and primary and secondary outcomes intended for the focus of this review, N=63 articles were retrieved and read in full by the researchers. These articles were included in the final integrative review. Depression in fathers following the birth of their child was associated with a personal history of depression and with the existence of depression in their partner during pregnancy and soon after delivery. Based on the review the authors suggest routine screening and assessment of both parents should occur across the pregnancy and postnatal period. The use of the Edinburgh Postnatal Depression Scale for screening of depression in men needs to be linked to referral guidelines for those individuals who require further investigation and care.

Journal ArticleDOI
11 Aug 2015-JAMA
TL;DR: In Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities, suggesting that different factors may account for disparities in referral.
Abstract: Importance Dialysis facilities in the United States are required to educate patients with end-stage renal disease about all treatment options, including kidney transplantation. Patients receiving dialysis typically require a referral for kidney transplant evaluation at a transplant center from a dialysis facility to start the transplantation process, but the proportion of patients referred for transplantation is unknown. Objective To describe variation in dialysis facility–level referral for kidney transplant evaluation and factors associated with referral among patients initiating dialysis in Georgia, the US state with the lowest kidney transplantation rates. Design, Setting, and Participants Examination of United States Renal Data System data from a cohort of 15 279 incident, adult (18-69 years) patients with end-stage renal disease from 308 Georgia dialysis facilities from January 2005 to September 2011, followed up through September 2012, linked to kidney transplant referral data collected from adult transplant centers in Georgia in the same period. Main Outcomes and Measures Referral for kidney transplant evaluation within 1 year of starting dialysis at any of the 3 Georgia transplant centers was the primary outcome; placement on the deceased donor waiting list was also examined. Results The median within-facility percentage of patients referred within 1 year of starting dialysis was 24.4% (interquartile range, 16.7%-33.3%) and varied from 0% to 75.0%. Facilities in the lowest tertile of referral ( 31.3%). In multivariable, multilevel analyses, factors associated with lower referral for transplantation, such as older age, white race, and nonprofit facility status, were not always consistent with the factors associated with lower waitlisting. Conclusions and Relevance In Georgia overall, a limited proportion of patients treated with dialysis were referred for kidney transplant evaluation between 2005 and 2011, but there was substantial variability in referral among facilities. Variables associated with referral were not always associated with waitlisting, suggesting that different factors may account for disparities in referral.

Journal ArticleDOI
01 Jan 2015-BMJ Open
TL;DR: Investigation of access to weight management interventions for overweight and obese patients in primary care found limited evidence may result from poor recording of advice given, but may indicate a lack of patient access to appropriate body weightManagement interventions inPrimary care.
Abstract: Objectives To investigate access to weight management interventions for overweight and obese patients in primary care. Setting UK primary care electronic health records. Participants A cohort of 91 413 overweight and obese patients aged 30–100 years was sampled from the Clinical Practice Research Datalink (CPRD). Patients with body mass index (BMI) values ≥25 kg/m 2 recorded between 2005 and 2012 were included. BMI values were categorised using WHO criteria. Interventions Interventions for body weight management, including advice, referrals and prescription of antiobesity drugs, were evaluated. Primary and secondary outcome measures The rate of body weight management interventions and time to intervention were the main outcomes. Results Data were analysed for 91 413 patients, mean age 56 years, including 55 094 (60%) overweight and 36 319 (40%) obese, including 4099 (5%) with morbid obesity. During the study period, 90% of overweight patients had no weight management intervention recorded. Intervention was more frequent among obese patients, but 59% of patients with morbid obesity had no intervention recorded. Rates of intervention increased with BMI category. In morbid obesity, rates of intervention per 1000 patient years were: advice, 60.2 (95% CI 51.8 to 70.4); referral, 75.7 (95% CI 69.5 to 82.6) and antiobesity drugs 89.9 (95% CI 85.0 to 95.2). Weight management interventions were more often accessed by women, older patients, those with comorbidity and those in deprivation. Follow-up of body weight subsequent to interventions was infrequent. Conclusions Limited evidence of weight management interventions in primary care electronic health records may result from poor recording of advice given, but may indicate a lack of patient access to appropriate body weight management interventions in primary care.

Journal ArticleDOI
TL;DR: It is demonstrated that access to treatment of Chagas disease in the United States is limited because the lack of licensing is only one of several barriers to access, highlighting the need for a health systems perspective when scaling up access to these essential medicines.
Abstract: There are 300,000 estimated cases of Chagas disease in the United States but limited data on access to care. This study analyzed trends in access to care for Chagas disease in the United States and assessed the national and state barriers to access. Data on cases in blood donors and drug releases were obtained from the AABB (formerly American Association of Blood Banks) and U.S. Centers for Disease Control and Prevention (CDC), respectively. Semi-structured in-depth interviews were conducted with 30 key informants at the national level and in five states where treatment had been released. Interview responses were analyzed according to the health systems dimensions of regulation, financing, payment, organization, and persuasion. Data indicate that 1,908 cases were identified in the blood donation system from 2007 to 2013 and that CDC released 422 courses of benznidazole or nifurtimox during this period. The barriers to access at the national level include limited diagnostic and institutionalized referral and care processes, lack of financing for patient-care activities, and limited awareness and training among providers. This study demonstrates that access to treatment of Chagas disease in the United States is limited. The lack of licensing is only one of several barriers to access, highlighting the need for a health systems perspective when scaling up access to these essential medicines.

Journal ArticleDOI
TL;DR: Early integration of pediatric palliative care (PPC) for children with life-threatening conditions and their families enhances the provision of holistic care, addressing psychological, social, spiritual, and physical concerns, without precluding treatment with the goal of cure as mentioned in this paper.
Abstract: Early integration of pediatric palliative care (PPC) for children with life-threatening conditions and their families enhances the provision of holistic care, addressing psychological, social, spiritual, and physical concerns, without precluding treatment with the goal of cure. PPC involvement ideally extends throughout the illness trajectory to improve continuity of care for patients and families. Although current PPC models focus primarily on the hospital setting, community-based PPC (CBPPC) programs are increasingly integral to the coordination, continuity, and provision of quality care. In this review, the authors examine the purpose, design, and infrastructure of CBPPC in the United States, highlighting eligibility criteria, optimal referral models to enhance early involvement, and fundamental tenets of CBPPC. This article also appraises the role of CBPPC in promoting family-centered care. This model strives to enhance shared decision making, facilitate seamless handoffs of care, maintain desired locations of care, and ease the end of life for children who die at home. The effect of legislation on the advent and evolution of CBPPC also is discussed, as is an assessment of the current status of state-specific CBPPC programs and barriers to implementation of CBPPC. Finally, strategies and resources for designing, implementing, and maintaining quality standards in CBPPC programs are reviewed.

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TL;DR: The quality of OA care as assessed by a meta-analysis of QI pass rates across studies was suboptimal for all treatment domains, indicating the wide divergence between evidence and consensus-based recommended care and practice has been reaffirmed.
Abstract: Rationale, aims and objectives: Quality indicators (QIs) derived from the review of medical records, administrative databases, and patient questionnaires and interviews have been frequently used to assess the quality of osteoarthritis (OA) care. The purpose of this review is to summarize studies that have assessed the quality of OA care using QIs. Method: We systematically searched MEDLINE, EMBASE, CINAHL and PsycINFO for English-language studies indexed by October 2014. Articles were included if they used any QIs for assessing the quality of OA care. We summarized the results of these studies, and with meta-analysis, generated an overall conclusion about the quality of care as measured by QIs for each treatment domain for OA care. Results: Fourteen studies assessed as being of high-quality were included in the review, with the number of QIs ranging from 1 to 21. Four of the 14 studies solely assessed the quality of OA care, while the other studies assessed health care quality for a range of conditions that included OA. The quality of OA care as assessed by a meta-analysis of QI pass rates across studies was suboptimal for all treatment domains (pass rates: pain and functional status assessment -48.5%, 95% CI 32.6-64.6%; non-drug treatment -36.1%, 95% CI 27.8-44.7%; drug treatment -37.5%, 95% CI 30.8-44.5%; surgical referral -78.9%, 95% CI 57.4-94.2%). Conclusion: Despite efforts made at improving care for patients with OA, the wide divergence between evidence and consensus-based recommended care and practice has been reaffirmed.

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TL;DR: The evidence supporting the integration of palliative care into comprehensive cancer care is reviewed, perceived barriers to palliatives care in hematologic malignancies are discussed, and opportunities and triggers for earlier and more frequent palliATIVE care referral in this population are suggested.
Abstract: Palliative care is a multidisciplinary approach to symptom management, psychosocial support, and assistance in treatment decision-making for patients with serious illness and their families. It emphasizes well-being at any point along the disease trajectory, regardless of prognosis. The term "palliative care" is often incorrectly used as a synonym for end-of-life care, or "hospice care". However, palliative care does not require a terminal diagnosis or proximity to death, a misconception that we will address in this article. Multiple randomized clinical trials demonstrate the many benefits of early integration of palliative care for patients with cancer, including reductions in symptom burden, improvements in quality-of-life, mood, and overall survival, as well as improved caregiver outcomes. Thus, early concurrent palliative care integrated with cancer-directed care has emerged as a standard-of-care practice for patients with cancer. However, patients with hematologic malignancies rarely utilize palliative care services, despite their many unmet palliative care needs, and are much less likely to use palliative care compared to patients with solid tumors. In this article, we will define "palliative care" and address some common misconceptions regarding its role as part of high-quality care for patients with cancer. We will then review the evidence supporting the integration of palliative care into comprehensive cancer care, discuss perceived barriers to palliative care in hematologic malignancies, and suggest opportunities and triggers for earlier and more frequent palliative care referral in this population.

Journal ArticleDOI
TL;DR: A consensual ASAS-endorsed referral recommendation for patients suspected of having axial spondyloarthritis was developed as a flexible and universal strategy to be used in clinical practice by primary care physicians or non-rheumatology specialists.
Abstract: The aim of this work was to develop a consensual recommendation under the auspices of the Assessment of SpondyloArthritis international Society (ASAS) for early referral of patients with a suspicion of axial spondyloarthritis by non-rheumatologists. The development of a referral recommendation consisted of four phases: (1) systematic literature review, (2) the first Delphi round aiming at identification of unmet needs and development of a candidate list of referral parameters, (3) the second Delphi round aiming at identification of the most useful combination of referral parameters and (4) final discussion and formal endorsement by ASAS membership. The following consensus on a referral recommendation was achieved as a result of the Delphi processes and final voting: “Patients with chronic back pain (duration ≥3 months) and back pain onset before 45 years of age should be referred to a rheumatologist if at least one of the following parameters is present: Inflammatory back pain; human leucocyte antigen-B27; Sacroiliitis on imaging if available (X-rays or magnetic resonance imaging); Peripheral manifestations (arthritis, enthesitis, dactylitis); Extra-articular manifestations (psoriasis, inflammatory bowel disease, uveitis); Positive family history for spondyloarthritis; Good response to non-steroidal anti-inflammatory drugs; Elevated acute phase reactant.” A consensual ASAS-endorsed referral recommendation for patients suspected of having axial spondyloarthritis was developed as a flexible and universal strategy to be used in clinical practice by primary care physicians or non-rheumatology specialists. The practical value of this strategy applied in different settings should be determined in future studies.

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TL;DR: When provided with services to address health-related social problems, the majority of youth choose to receive help, with nearly half successfully addressing their priority concern.

Journal ArticleDOI
13 Oct 2015-BMJ
TL;DR: Use of the urgent referral pathway could be efficacious and general practices that consistently have a low propensity to use urgent referrals could consider increasing the use of this pathway to improve the survival of their patients with cancer.
Abstract: Objective To assess the overall effect of the English urgent referral pathway on cancer survival. Setting 8049 general practices in England. Design Cohort study. Linked information from the national Cancer Waiting Times database, NHS Exeter database, and National Cancer Register was used to estimate mortality in patients in relation to the propensity of their general practice to use the urgent referral pathway. Participants 215 284 patients with cancer, diagnosed or first treated in England in 2009 and followed up to 2013. Outcome measure Hazard ratios for death from any cause, as estimated from a Cox proportional hazards regression. Results During four years of follow-up, 91 620 deaths occurred, of which 51 606 (56%) occurred within the first year after diagnosis. Two measures of the propensity to use urgent referral, the standardised referral ratio and the detection rate, were associated with reduced mortality. The hazard ratio for the combination of high referral ratio and high detection rate was 0.96 (95% confidence interval 0.94 to 0.99), applying to 16% (n=34 758) of the study population. Patients with cancer who were registered with general practices with the lowest use of urgent referral had an excess mortality (hazard ratio 1.07 (95% confidence interval 1.05 to 1.08); 37% (n=79 416) of the study population). The comparator group for these two hazard ratios was the remaining 47% (n=101 110) of the study population. This result in mortality was consistent for different types of cancer (apart from breast cancer) and with other stratifications of the dataset, and was not sensitive to adjustment for potential confounders and other details of the statistical model. Conclusions Use of the urgent referral pathway could be efficacious. General practices that consistently have a low propensity to use urgent referrals could consider increasing the use of this pathway to improve the survival of their patients with cancer.