Referral

About: Referral is a research topic. Over the lifetime, 27614 publications have been published within this topic receiving 479918 citations.

The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community

Abstract: Pre-eclampsia is a major cause of poor outcome in pregnancy: the category “hypertensive diseases of pregnancy” remains a leading cause of direct maternal deaths in the United Kingdom1; pre-eclamptic conditions represent one in three cases of severe obstetric morbidity2; hypertension and/or proteinuria is the leading single identifiable risk factor in pregnancy associated with stillbirth (one in five stillbirths in otherwise viable babies)3; and pre-eclampsia is strongly associated with fetal growth restriction, low birth weight, preterm delivery, respiratory distress syndrome, and admission to neonatal intensive care.4 In 46% of maternal deaths1 and 65% of fetal deaths5 due to pre-eclampsia reported through the Confidential Enquiries into Maternal Deaths and the Confidential Enquiry into Stillbirths and Deaths in Infancy, different management would reasonably have expected to alter the outcome. There was a failure to identify and act on known risk factors at booking and to recognise and respond to signs and symptoms from 20 weeks' gestation.6 No guidelines exist for the screening and early detection of pre-eclampsia in the community, and there is no uniformity in referral thresholds and assessment procedures. We developed the pre-eclampsia community guideline (PRECOG) under the auspices of the charity Action on Pre-eclampsia, following the National Institute for Clinical Excellence's recommendations for the development of guidelines.7 Our guideline is supported by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the Royal College of General Practitioners, and the National Childbirth Trust. Box 1 lists the definitions used in the guideline; pre-eclampsia is defined as new hypertension and proteinuria (see bmj.com for definition of levels of evidence). The pre-eclampsia community guideline provides an evidence based risk assessment, with criteria for early referral for specialist input, a two tiered schedule for monitoring women in the community after …

Primary Care Physicians' Approach to Depressive Disorders Effects of Physician Specialty and Practice Structure

Abstract: Background Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal. Objective To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders. Methods A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care. Results Of 2316 physicians with known eligibility, 1350 (58.3%) returned the questionnaire. Respondents were family physicians (n = 621), general internists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs report recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9%), diagnosis based on formal criteria (33.7%), direct questioning about suicide (58%), and assessment for substance abuse (68.1%) or medical causes of depression (84.1%). Reported treatment practices were watchful waiting only (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant medication prescription (72.5%), and mental health referral (38.4%). Diagnostic evaluation and treatment approaches varied significantly by specialty but not by the type of depression or degree of capitation. Physician barriers differed by specialty more than by degree of capitation. In contrast, organizational barriers, such as time for an adequate history and the affordability of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were common but did not vary by physician specialty or degree of capitation. Conclusions A substantial proportion of PCPs report diagnostic and treatment approaches that are consistent with high-quality care. Differences in approach were associated more with specialty than with type of depressive disorder or degree of capitation. Quality improvement efforts need to (1) be tailored for different physician specialties, (2) emphasize the importance of differentiating major depression from other depressive disorders and tailoring the treatment approach accordingly, and (3) address organizational barriers to best practice and knowledge gaps about depression treatment.

When the treatment goal is not cure: are cancer patients equipped to make informed decisions?

Abstract: PURPOSE: Informed decision making now is considered the underpinning of ethical medical practice. We aimed to determine the extent to which patients with incurable cancer are adequately informed of their prognosis and treatment options and encouraged to participate in treatment decisions. PATIENTS AND METHODS: One hundred eighteen cancer patients with incurable disease presenting for an initial consultation with one of nine oncologists at two Sydney tertiary referral hospitals participated in the study. Consultations were recorded on audiotape to permit a content analysis of doctor-patient interactions. We devised a coding system to assess disclosure of information and to evaluate doctor encouragement of patient participation in treatment decision making. Patient recall, satisfaction, anxiety, and perceptions of the decision-making process were assessed to determine the effects of informed decision making on patient outcomes. RESULTS: Most patients were informed about the aim of anticancer treatment (84.7...

Challenges in palliative care research; recruitment, attrition and compliance: experience from a randomized controlled trial

Abstract: Randomized controlled trials (RCTs) in palliative cancer care often experience methodological problems. In this paper we discuss issues of major concern, including recruitment, patient attrition and compliance, arising from an RCT that compared comprehensive palliative care to conventional care. The main criteria for trial entry were incurable malignant disease and a survival expectancy of between 2 and 9 months. Patients' health-related quality of life (HRQL), self-assessed by multi-item questionnaires, was a defined endpoint. The planned number of patients was successfully recruited, although the patients were referred late in the course of their disease so that follow-up tended to be short. Compliance in completing HRQL questionnaires was good up to 1 month before the patient's death; but in the final weeks it was found to drop substantially. Based on our experience, recommendations are given for those planning similar research. Procedures for improving patient recruitment are suggested, stressing the need for local data management, repeated information to referral sources, extensive screening for potentially eligible patients and simple referral routines. Precise inclusion criteria, including prognostic factors other than physicians' estimates of life expectancy, should be used to ensure a sufficient follow-up period. For HRQL assessment, multi-item questionnaires can achieve excellent compliance up to 1 month before patients' death, but in order to evaluate the very final weeks of life we recommend the use of simpler methods.