[Drug consultation for a terminal cancer patient at home care-management of dyspnea and pain by morphine]

We studied on the points of that a management of dyspnea and pain by morphine for a terminal cancer patient at Home care. It was suggested that a necessary on management of symptoms for a terminal cancer patient before home drug therapy, a education to patient and his family by drug consultation before and after home drug therapy, a confirmation of dyspnea and pain for a terminal cancer patient from one drug to the next, and a importance of communication between medical staffs.

New model helps find missing link between financial and clinical health care management

U.S. health care is missing a link between the financial managers and clinical health managers of defined patient populations. Utilization and cost management try to bridge the gap by focusing on restricted access to care or tightly managed provider reimbursement to control costs. But frequently, they do not take clinical outcomes or health status into consideration. Take a look at another method based on the science of epidemiology that brings a more balanced knowledge of the clinical world to financial managers and more financial insight to clinicians.

Pharmaceutical care needs of patients with angina

OBJECTIVE

The aim of this study was to evaluate patient knowledge and assess the management of angina for patients receiving sublingual glyceryl trinitrate (GTN) METHOD: Prospective data collection and patient interview was undertaken in 17 community pharmacies.

RESULTS

During the study 488 angina patients presented to the participating pharmacies. Data were collected for 347 patients receiving sublingual GTN. Problems with administration technique were identified for 108 patients (31%) and knowledge of when to seek medical help appropriately after failed GTN use was unsure for 134 patients (39%) or poor for 88 patients (25%). Eighty five patients (24%) were not receiving regular symptomatic therapy. Aspirin was prescribed or purchased by 253 patients (73%). Seven pharmacies participated in GP referral (data collected for 201 patients); 31 patients (15%) were referred usually with a recommendation to add aspirin. The outcome of 20 of these referrals was assessed; advice was taken for 13 patients, 3 patients failed to attend GP, aspirin was contraindicated for 3 patients and one patient already attended pharmacist medication review.

CONCLUSION

This study demonstrated the potential contribution community pharmacists could make at the time of dispensing to the management of patients with angina.

Managing ambulatory anticoagulation

This overview of the management of ambulatory oral anticoagulant therapy addresses the importance of patient education and highlights tested educational techniques; describes issues of documentation of the patient encounter in the medical record; and reviews drug dosage adjustments, the management of patients with high International Normalized Ratio (INR) values, and the recommended changes of oral anticoagulation for patients who undergo invasive procedures.

Management practices among primary care physicians and thyroid specialists in the care of hypothyroid patients

Prospective studies are not available to address various issues commonly encountered in the management of hypothyroid patients. We have conducted a case-based mail survey of American Thyroid Association (ATA) members and primary care providers (PCP) regarding hypothyroidism management issues. A majority of ATA members and a minority of PCPs used antithyroid antibody testing in the evaluation of hypothyroidism. Approximately 2/3 of all respondents indicated that they would treat patients with mild thyroid failure when antithyroid antibodies are negative; 77% of PCPs and 95% of ATA members recommended treatment when antibodies are positive. For a young patient with mild thyroid failure, 71% of ATA members would initiate a full levothyroxine (LT4) replacement dose of 1.6 microg/kg per day or slightly lower; PCPs were more likely to start with a low dose and titrate upwards. For a young patient with overt hypothyroidism, 42% of PCPs and 51% of ATA respondents recommended an initial full LT4 replacement dose. The majority of all respondents would start with a low LT4 dose and adjust the dose gradually in an elderly patient, regardless of the severity of thyroid hormone deficiency. More than 40% of ATA respondents chose a target thyrotropin (TSH) range of 0.5-2.0 microU/mL for a young patient while 39% favored a goal of 1.0-4.0 microU/mL for an elderly patient. PCPs more often chose a broader TSH goal of 0.5-5.0 microU/mL. In conclusion, the current practice patterns of PCPs and ATA members that were elicited in this survey differ significantly in regard to the evaluation and management of hypothyroidism.

The socio-organizational age of artificial intelligence in medicine

The increasing pressure on Health Care Organizations (HCOs) to ensure efficiency and cost-effectiveness, balancing quality of care and cost containment, will drive them towards a more effective management of medical knowledge derived from research findings. The relation between science and health services has until recently been too casual. The primary job of medical research has been to understand the mechanisms of disease and produce new treatments, not to worry about the effectiveness of the new treatments or their implementation. As a result many new treatments have taken years to become part of routine practice, ineffective treatments have been widely used, and medicine has been opinion rather than evidence based. This results in suboptimal care for patients. Knowledge management technology may provide effective approaches in speeding up the diffusion of innovative medical procedures whose clinical effectiveness have been proved: the most interesting one is represented by computer-based utilization of evidence-based clinical guidelines. As researchers in Artificial Intelligence in Medicine (AIM), we are committed to foster the strategic transition from opinion to evidence-based decision making. Reviews of the effectiveness of various methods of guideline dissemination show that the most predictable impact is achieved when the guideline is made accessible through computer-based and patient specific reminders that are integrated into the clinician's workflow. However, the traditional single doctor-patient relationship is being replaced by one in which the patient is managed by a team of health care professionals, each specializing in one aspect of care. Such shared care depends critically on the ability to share patient-specific information and medical knowledge easily among them. Strategically there is a need to take a more clinical process view of health care delivery and to identify the appropriate organizational and information infrastructures to support this process. Thus, the great challenge for AIM researchers is to exploit the astonishing capabilities of new technologies to disseminate their tools to benefit HCOs by assuring the conditions of knowledge management and organizational learning at the fullest extent possible. To achieve such a strategic goal, a guideline can be viewed as a model of the care process. It must be combined with an organization model of the specific HCO to build patient careflow management systems. Artificial intelligence can be extensively used to design innovative tools to support all the development stages of those systems. However, exploiting the knowledge represented in a guideline to build them requires to extend today's workflow technology by solving some challenging problems.

A survey of trainee obstetricians preferences for childbirth

OBJECTIVE

To determine trainee obstetricians personal preferences regarding mode and place of delivery given various scenarios.

STUDY DESIGN

An anonymous nationwide postal survey of 365 specialist registrars.

RESULTS

The response rate was 76%. About 2.5% preferred a home birth. And 16% of men and 15% of women opted for elective cesarean section (CS). When faced with a proposed trial of instrumental delivery in theatre, 60% accepted and a further 12% accepted only if they could choose the obstetrician performing the delivery. Regarding a breech presentation at term, 78% would accept external cephalic version (ECV).

CONCLUSIONS

The percentage of obstetricians who preferred vaginal delivery and ECV were considerably higher than previously reported, and there were no significant gender differences. This study shows a more balanced attitude from obstetricians and refutes the previously held view that they necessarily advocate high levels of intervention for themselves.

Flexible guideline-based patient careflow systems

Workflow Management Systems integrate domain and organisational knowledge to support business processes. When applied to the medical environment, they can be termed "Careflow Management Systems", and may be used to manage care delivery by enhancing co-operation among healthcare professionals. This paper focuses on care delivery based on clinical practice guidelines. Healthcare organisations are very different from industrial or commercial companies: their main goal is not profit, but maintaining and improving the health of the public. Therefore, outcomes are difficult to measure. Firstly, physicians, while playing a variety of roles, are quite independent decision-makers; secondly, the object of the process, i.e. the patient, may be involved in choosing treatment options, and may be treated by different institutions. For these reasons, the standard functionality of typical Workflow Management Systems must be strongly enhanced in order to cope with healthcare delivery needs. A major issue is accounting for exceptions. In most non-clinical settings this is not a problem because processes are very well defined and can often be easily controlled by some higher authority. As explained above, this does not happen in healthcare organisations. Responsibilities are widely shared, and health care professionals may be non-compliant with guidelines for a variety of reasons. The paper presents a classification of possible exceptions, and shows how the sequence of tasks described by a guideline may be altered, at the implementation level, in order to meet actual user needs, while maintaining guideline intentions as much as possible. A terminology server is also exploited towards this end. This work illustrates a prototype of a Careflow Management System based on an international guideline for ischemic stroke treatment, developed by the American Heart Association.

The future of capitation: the physician role in managing change in practice

Capitation-based reimbursement significantly influences the practice of medicine. As physicians, we need to assure that payment models do not jeopardize the care we provide when we accept higher levels of personal financial risk. In this paper, we review the literature relevant to capitation, consider the interaction of financial incentives with physician and medical risk, and conclude that primary care physicians need to work to assure that capitated systems incorporate checks and balances which protect both patients and providers. We offer the following proposals for individuals and groups considering capitated contracts: (1) reimbursement for primary care physicians should recognize both individual patient encounters and the administrative work of patient care management; (2) reimbursement for subspecialists should recognize both access to subspecialty knowledge and expertise as well as patient care encounters, but in some situations, subspecialists may provide the majority of care to individual patients and will be reimbursed as primary care providers; (3) groups of physicians should accept financial risk for patient care only if they have the tools and resources to manage the care; (4) physicians sharing risk for patient care should meet regularly to discuss care and resource management; and (5) physicians must disclose the financial relationships they have with health plans and medical care organizations, and engage patients and communities in discussions about resource allocation. As a payment model, capitation offers opportunities for primary care physicians to influence the future of health care by improving the management of resources at a local level.

Improving the quality of postoperative pain relief

A review of the literature shows a constant need to improve the quality of postoperative pain management. The objective of this study was to decrease the intensity and variation of postoperative pain by developing a nurse-based pain service on the ward. An acute pain nurse was appointed and an educational programme with detailed algorithms was started. Regular pain intensity measurements were implemented. Postoperative pain intensity, treatments and side-effects were assessed both before and after the introduction of the new system in 400 patients divided into two consecutive groups of equal size. The number of patients with inadequately treated pain (actual pain > 3/10) dropped by 64% after major gynaecological surgery (25 vs 9%, 95% CI for differences 7-24%; p<0.001 for pain scores). On an average, inadequate pain relief (retrospective average pain > 3/10) on the first postoperative day was more frequent on the ward before than after the reform (47 vs. 21%; 95% CI for differences 15-35%; p<0.001 for pain scores). The incidence of side-effects was similar in both groups (p> 0.05). The intensity and variation of postoperative pain on the ward decreased by developing a nurse-based pain service with an acute pain nurse, an educational programme and regular pain intensity measurements.

An orthodontic patient administration system (OPAS) for complete departmental management

There is a requirement for effective management and audit in today's hospital environment. This paper discusses some of the principal requirements of a computer program for comprehensive orthodontic department management and describes in detail one system.

Regional access to acute ischemic stroke intervention

BACKGROUND AND PURPOSE

Benefit-risk ratios from recombinant tissue plasminogen activator (rtPA) therapy for acute ischemic stroke demonstrate lack of efficacy if intravenous administration is commenced beyond 3 hours of symptom onset. We undertook to enhance therapeutic effectiveness by ensuring equitable access to rtPA for patients affected by acute ischemic stroke within a 20 000 km(2) population referral base served by a tertiary facility.

METHODS

Representatives of all provider groups involved in emergency medical services developed a Regional Acute Stroke Protocol (RASP), a coordinated regional system response by dispatch personnel, paramedics, physicians, community service providers, emergency and inpatient staff in community hospitals, and the tertiary facility acute stroke team.

RESULTS

As of July 26, 1999, all ambulance services in Southeastern Ontario began bypassing the closest hospital to deliver patients meeting the criteria for the RASP to the Kingston General Hospital. At 12 months, approximately 403 ischemic strokes have occurred in the region, the RASP has been activated 191 times, and 42 patients have received rtPA.

CONCLUSIONS

We conclude that (1) acute stroke patients in Southeastern Ontario have improved access to interventions for stroke care; (2) geography of the region is not a barrier to access to interventions for patients with acute stroke; and (3) acute ischemic stroke patients treated with rtPA account for 5% of all acute strokes and 10% of all ischemic strokes in this region.

Canadian Aboriginal communities and medical service patterns for the management of injured patients: a basis for surveillance

Growing attention has been placed on injury as a major public health problem which has served to highlight the need for relevant injury data for preventive purposes at the community level. In the case of reserve-based Aboriginal communities in Canada, available injury data, from large datasets, often has little or no relevance at the community level. In addition, the availability of local data is complicated by unique health service and community infrastructures. As such, a prerequisite to establishing injury surveillance requires an understanding of Medical Service Patterns (MSPs) for injured patients intrinsic to a community's health service infrastructure. In determining patterns, cultural and environmental contexts are integral to methodological considerations as historically, Canada's Aboriginal population has been 'controlled' by others in the areas of health, education and social services. The objective of the study was to investigate MSPs in a Canadian Aboriginal community, specific to the management of injured patients, for the purpose of identifying data sites, sources, and collectors. The method relied on a four-step qualitative process designed explicitly for the study community, comprising: (1) semi-structured interviews with key informants; (2) a flow diagram process; (3) focus group discussions; and (4) a summary matrix diagram. This methodology was later replicated with three additional pilot communities. Three major MSPs were identified from nine original patterns generated through the initial data collection process. MSPs were found to be most directly impacted by severity of injury and the proximity of health service providers. Data collection practices were inconsistent, sporadic and poorly coordinated. Data was exclusive to respective data sources and off-reserve documentation was not reported back to the community. MSPs identified key data sites, sources, and collectors relevant to the study population. In conclusion, the four-step qualitative methodology employed in the study was found to be reliable and feasible in identifying community MSPs. Empirical findings confirm the need to investigate MSPs in communities considering surveillance activities, as intra-national differences may be considerable given social inequalities, geographic uniqueness and cultural factors. The use of sophisticated methodologies may detract rather than promote collaborative efforts.

Predictors of outcome in a primary care depression trial

OBJECTIVE

Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response.

DESIGN

Randomized trial of a stepped collaborative care intervention versus usual care.

SETTING

HMO in Seattle, Wash.

PATIENTS

Patients with major depression were stratified into severe (N = 149) and mild to moderate depression (N = 79) groups prior to randomization.

INTERVENTIONS

A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician.

MEASUREMENTS AND MAIN RESULTS

Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z = -3.06, P<.002); however, this difference was not present in the more severely depressed groups (z = 0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months.

CONCLUSIONS

Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes.

Management of laboratory test results in family practice. An OKPRN study. Oklahoma Physicians Resource/Research Network

BACKGROUND

Ineffective management of laboratory test results can result in suboptimal care and malpractice liability. However, there is little information available on how to do this important task properly in primary care settings.

METHODS

We used a questionnaire guided by a literature review to identify a conceptual model, current practices, and clinicians who reported having an effective method for at least one of 4 steps in the process of managing laboratory test results. Clinicians with differing methods were selected for each of the steps. Practice audits and patient surveys were used to determine actual performance. On the basis of these audits, we constructed a unified best method and conducted time-motion studies to determine its cost.

RESULTS

After auditing only 4 practices we were able to identify effective methods for 3 of the 4 steps involved in the management of laboratory test results. The unified best method costs approximately $5.19 per set of tests for an individual patient.

CONCLUSIONS

By identifying effective practices within a family practice research network, an effective method was identified for 3 of the 4 steps involved in the management of laboratory test results in primary care settings.

Psychiatric assessment wards for older adults: a qualitative evaluation of two ward models

This study was requested to investigate the relative strengths of two different ward arrangements. Both wards were psychiatric assessment wards for people over the age of 65 and both were mixed sex wards. The major focus was to examine if the separation of cognitively impaired (CI) and functional clients on an elderly assessment ward had benefits in terms of client and staff satisfaction. The study involved 192 hours of observation, following four clients on each ward for 24-hours. Results indicate that the split ward and the mixed ward differ qualitatively and that in terms of user and staff satisfaction the split model is preferable. Implications for service development and future research are also discussed.

Patient management strategies and transplantation techniques in european stem cell transplantation centers offering breast cancer patients high-dose chemotherapy with peripheral blood stem cell support: a joint report from the EORTC and EBMT

BACKGROUND AND OBJECTIVES

It is increasingly being realized that there are very considerable variations in individual hospitals' strategies for managing a particular group of patients, even if using similar therapeutic regimens. Such variations make it impossible to generalize estimations of treatment costs from one setting to others. The objective of this study is to examine the extent of variation in the current approaches in Europe to peripheral blood stem cell transplantation (PBSCT) in breast carcinoma.

DESIGN AND METHODS

A questionnaire was developed and sent to the EBMT member institutions. The questionnaire comprised 85 questions covering the technical and clinical issues involved and the strategies followed for the management of the patients. This paper reports the results of the survey primarily by means of descriptive, univariate frequency distributions. The results of a more analytical approach, aiming at explaining patterns in the variations observed are also presented.

RESULTS

A completed questionnaire was returned by 162 centers; 60% university hospitals, 14% cancer centers and the rest general hospitals. Considerable variations are observed between the centers with respect to all aspects of patient management and technical procedures investigated. In many respects, general hospitals follow different routines from university hospitals and dedicated cancer centers.

INTERPRETATION AND CONCLUSIONS

Variability to the extent observed indicates an important scope for optimization of the procedures and a large potential for reduction of costs and perhaps for improvement of outcomes. Economic evaluations, for instance comparing PBSCT with autologous BMT as support for high dose chemotherapy, can not be generalized from one setting to another without careful examination of the procedures and strategies followed in each setting. European hospitals treating breast cancer patients with high dose chemotherapy supported by transplantation of peripheral blood stem cells use very different technical procedures for mobilization, harvest and re-implantation of stem cells. In addition, there are also wide variations in the way they manage the patients, e.g. with regard to the criteria for discharge from hospital after re-implantation.

Increasing the cost-effectiveness of telemedicine by embracing e-health

In 1999 a national study of telemedicine in Australia led to the promotion of the concept of 'e-health', the health sector's equivalent of 'e-commerce'. A new study explored the view that, with the convergence of technologies and the consequent increase in ability to perform multiple functions with those technologies, it is unwise to promote telemedicine in isolation from other uses of technologies in health-care. The major sources of information for the study were the presentations and discussions at five national workshops held to discuss the findings of the original report on telemedicine. Nineteen case studies were identified. The case studies showed that with the convergence of technologies telehealth is becoming part of e-health. The cost-effectiveness of both telehealth and telemedicine improves considerably when they are part of an integrated use of telecommunications and information technology in the health sector.

A comparison of telemedicine with face-to-face consultations for trauma management

We compared the accuracy of teleconsultations for minor injuries with face-to-face consultations. Two hundred patients were studied. Colour change, swelling, decreased movement, tenderness, instability, radiological examination, severity of illness, treatment and diagnosis were recorded for both telemedicine and face-to-face consultations. Colour change showed an accuracy of 97%, presence of swelling or deformity of 98%, diminution of joint movement of 95%, presence of tenderness of 97%, weight bearing and gait of 99%, and radiological diagnosis of 98%. The severity of illness or injury was overestimated in one case and underestimated in five cases. Treatment was over-prescribed in one case and under-prescribed in three cases. The final diagnosis was correct in all but the two cases in which mistakes were made in the teleradiology. Overall, there was good accuracy using teleconsultations.

Transfer of telemedical support to Cornwall from a national telemedicine network during a solar eclipse

During late 1998 and early 1999, planning officers in Cornwall predicted a huge increase in summer visitors to the county to observe the August solar eclipse. There was the possibility that a mass gathering in Cornwall could overload existing arrangements for handling accident and emergency patients. We therefore set up a telemedicine system to support the county's minor injury units (MIUs) from hospitals throughout the UK. Six main hospital accident and emergency departments outside Cornwall with existing links to their own MIUs were twinned with 10 of the 11 MIUs in Cornwall before the expected date of the gathering. The network was live for nine days, starting four days before the eclipse, and 2045 patients were seen in the 10 MIUs. There were 93 telemedicine calls from the 10 MIUs, involving 91 patients. Overall, 4.6% of the patients required a telemedicine consultation. Fifty-seven calls were made during working hours. Thirty-four patients were referred for further management, of whom 18 were referred on the same day. The transfer of telemedical support to a national network was successful.

Evaluating telemedicine for minor injuries units

Low-cost telemedicine equipment consisting of ISDN videoconferencing units and a store-and-forward system was installed in two minor injuries units (MIUs) and a hospital accident and emergency department in Lincolnshire. Over six months, 45 patients were treated using telemedicine in one MIU and 26 in another. Anecdotally, there were no reported radiograph discrepancies or missed diagnoses. Data collected during teleconsultations by both referring and consulting clinicians suggested that in some cases teleconsultation had helped to avoid transfer or onward referral. There were some changes in diagnosis and treatment after using telemedicine, indicating some decision-making value for the remote practitioners. In the context of minor injuries telemedicine, videoconferencing in realtime may prove to be more valuable than store-and-forward interactions. A cost-benefit analysis is being conducted using a pragmatic prospective case-control study.

Continuity of care and clinical outcome: a prospective cohort study

BACKGROUND

Continuity of care is a central objective of community psychiatric services, but there is no consensus about its measurement.

AIMS

We developed measures of continuity of care suitable for routine use, and measured continuity and individual patient outcome over a period in which community services were developing.

METHOD

One hundred patients with severe mental illness receiving continuing care from two sectorised services were sampled and interviewed. Data were collected concerning their care over 20 months prior to interview. After 20 months prospective follow-up, they were re-interviewed. Continuity was defined as: perceived accessibility of services and knowledge about them, the number of keyworkers in a defined period of time, and the proportion of time out of contact with services.

RESULTS

Continuity of care improved significantly on all measures over the period of the study. Individual patient outcome also improved, but in multiple regression models including clinical and demographic variables, measures of continuity were not significant predictors of outcome. Continuity was similar for white and non-white patients.

CONCLUSION

Simple measures of continuity are useful in evaluating changes in the process of care, but they are not straightforwardly related to individual outcome.

Community impact of anticoagulation services: rationale and design of the Managing Anticoagulation Services Trial (MAST)

We describe the design of the Managing Anti-coagulation Services Trial (MAST), a practice-improvement trial testing whether anticoagulation services are a preferred method of managing anticoagulation for stroke prevention among patients with atrial fibrillation. Most randomized trials within the health care environment are designed as efficacy studies to determine what works under ideal conditions or ideal clinical practice. In contrast, effectiveness trials seek to generalize the results of efficacy studies by determining what works under more typical practice conditions. Practice-improvement trials are effectiveness trials that examine the management of a clinical problem in the context in which care is usually given. Noteworthy features of the MAST include defining the intervention in functional terms and collaboration with managed care organizations.