Diagnosis and treatment in physical therapy: an investigation of their relationship

BACKGROUND AND PURPOSE

The diagnosis made by a physical therapist gives direction to the selection of therapeutic interventions. Therefore, in an investigation, specific relationships between diagnoses and therapeutic interventions are expected. This study was designed to test whether such relationships exist.

SUBJECTS AND METHODS

Data on diagnosis, treatment goals, and interventions were gathered on 8,714 patients by 74 physical therapists. The diagnosis and treatment goals were defined in terms of impairments and disabilities.

RESULTS

Specific relationships were found to exist between those impairments and disabilities that were chosen as a basis for forming treatment goals and the application of interventions. These relationships are particularly marked at the impairment level.

CONCLUSION AND DISCUSSION

It is concluded that the diagnostic categories validly predict which interventions are applied and that the selection of interventions depends on which treatment goals are pursued.

Specialty PPO helps a hospital "think like a business"

Borgess Medical Center's application of "clinical pathing" has enabled the institution to take a business approach to its operating procedures that has proven highly effective in achieving cost savings and improving delivery of services.

Use of MEDLINE by physicians for clinical problem solving

OBJECTIVE

To understand the ways in which computer-mediated searching of the biomedical literature affects patient care and other professional activities. Undertaken to determine the ways in which on-line access to the biomedical literature via the National Library of Medicine's MEDLINE database "makes a difference" in what physicians do when confronted with a medical problem requiring new or additional information.

DESIGN

An adaptation of the Critical Incident Technique used to gather detailed reports of MEDLINE search results that were especially helpful (or not helpful) in carrying out the individual's professional activities. The individual physician was the source of the patient care incident reports. One thousand one hundred fifty-eight reports were systematically analyzed from three different perspectives: (1) why the information was sought; (2) the effect of having (or not having) the needed information on professional decisions and actions; and (3) the outcome of the search.

PARTICIPANTS AND SETTING

Telephone interviews were carried out with a purposive sample of 552 physicians, scientists, and other professionals working in a variety of clinical care and other settings. Of these, 65% were direct users of MEDLINE throughout the United States, and 35% had MEDLINE searches conducted for them either at a major health sciences center or in community hospitals.

RESULTS

Three comprehensive and detailed inventories that describe the motivation for the searches, how search results affected the actions and decisions of the individual who initiated the search, and how they affected the outcome of the situation that motivated the search.

CONCLUSIONS

MEDLINE searches are being carried out by and for physicians to meet a wide diversity of clinical information needs. Physicians report that in situations involving individual patients, rapid access to the biomedical literature via MEDLINE is at times critical to sound patient care and favorably influences patient outcomes.

Evaluation and revision of a vasopressin/nitroglycerin protocol for use in variceal bleeding

BACKGROUND

Continuous infusion of IV vasopressin have been widely used to lower portal pressure and reduce bleeding from esophageal varices. Recently, the combination of vasopressin and nitroglycerin has been noted to be superior to vasopressin alone. This is due to the ability of nitroglycerin to reduce the detrimental effects of vasopressin while preserving its beneficial effects. In September 1989 the authors initiated a protocol in the medical intensive care unit of a large university teaching center that directed caregivers in the simultaneous use of vasopressin and nitroglycerin for use in variceal bleeding.

OBJECTIVE

To determine whether the protocol was being used correctly and whether the addition of nitroglycerin produced the desired cardiovascular effects.

METHOD

Nineteen patients (25 separate episodes) assigned to the vasopressin/nitroglycerin protocol were monitored retrospectively over a 20-month period for a total of 1068 hours of vasopressin/nitroglycerin infusion. Twenty-four patients received nitroglycerin at 10 to 50 micrograms per minute, 13 at 50 to 100 micrograms per minute and 6 at 100 to 400 micrograms per minute.

RESULTS

Nitroglycerin dosage was not advanced appropriately in 78% of episodes despite evidence of bradycardia, hypertension and peripheral vasoconstriction.

CONCLUSIONS

Revision of the protocol, giving additional guidance to clinicians on assessment and nitroglycerin advancement, was necessary and was accomplished.

Goal planning, needs assessment & advocacy

The White Paper, Health of the Nation, and the Patients' Charter both seek to emphasise the importance of fully involving and informing patients about the treatment they receive. Much work on implementation of these documents has concentrated on achieving specific targets which, although essential, ignore the key managerial theme of changing behaviour, approach and attitudes in the staff/patient relationship and ensuring that patients are empowered through this relationship. Paul Kennedy and Nigel Pearce suggest that carefully planned and managed change through the use of a comparatively simple and well established approach has a major impact on the achievement of these initiatives.

Better planning needed to strengthen patient-care systems

The word "change" is on everyone's lips this year. The desire for change in patient-care information applications is very strong, too, according to a recent Computers in Healthcare patient-care systems survey. Three nursing executives have studied the CIH survey results and give their view on why strategic planning for patient-care systems is so poor when the desire for these applications is so great.

[The methodology of quality control in parenteral nutrition. II. The application of the program to a therapeutic plan]

Patients subjected to parenteral nutrition (PN) must be treated based on a therapeutical plan which has been adapted to their nutritional and clinical needs within a normalizing framework. Furthermore, for this therapeutical plan to be effective and safe, not only must it be suitable for the patient, but also "exact" with regard to daily routines. The quality control programme designed was applied retrospectively to 148 patients. Evaluation was made based on the following indicators: a) delay in initiating parenteral nutrition, b) average intake of macronutrients, c) administration of micronutrients, d) duration of the PN, e) temporary interruptions of the PN, f) errors in medication and g) return of nutrient units. The compliance percentage obtained was 100, 100, 28.7, 89.5, 63.2 100 and 100 respectively. The results obtained have made it possible to understand the quality profile of the therapeutical plan applied to patients on PN. It is also a useful method for the continued improvement of this therapy.

Determination of virtual SSDs for electron beams from a dual energy linear accelerator

Electron beams from an accelerator appear to originate from a point away from the vacuum window designated as virtual source. Virtual source to isocenter distances are determined experimentally by measurements in a polystyrene phantom with inverse square law method. Corrections required for percentage depth dose are also determined. Results of our study are compared with that of other investigators.

[Care for the diabetic patient in Catalonia. A study of a population sample]

BACKGROUND

The aim of this study was to determine the clinical and therapeutic profile of both types of diabetics (IDDM and NIDDM) attended at different levels of health care in Cataluña in order to establish quality control and rationalize diabetologic sanitary planning.

METHODS

Fifteen centers in Cataluña participated in a study with a total of 1,430 patients. The centers represented different specialized care levels: 6 endocrinology public health out-patient clinics (EO), 4 county hospitals (CH), 3 university hospitals (UH) and 2 private diabetic units (DU).

RESULTS

IDDM: a) the percentage was higher in UH and DU (39 and 37) than in CH (26 p less than 0.01) and EO (11 p less than 0.001); b) the youngest were attended in UH (24 +/- 14 years) and the oldest in the EO (39 +/- 17 years, p less than 0.001), occupying the CH and DU at an intermediate position (34 +/- 16 and 32 +/- 17 years) and different than the other two (p less than 0.05); c) 74% of those attended in UH had an evolution of less than 10 years vs 45-58% of the other levels (p less than 0.005); d) no differences were observed in the overall prevalence of complications; e) 37% of the males between 15 and 64 years of age were smokers; f) intensive insulin therapy is more frequently used (p less than 0.05) in DU and UH (56% and 42%) than in EO and CH (19% and 13%); g) the determination of capillary glycemia is generalized (96%); h) 14% had HbA1 or fructosamine lower than the maximum normal value. NIDDM: a) the age of the patients was somewhat lower in DU (59 +/- 11) and UH (58 +/- 11) than in CH (62 +/- 100 and EO (64 +/- 10 (p less than 0.05); b) globally, the rate of insulinization was 55% and home control of glycemia was 43%; c) 47% are hypertense (half of whom are inadequately controlled) and 55% are dyslipemic; d) between 15 and 64 years of age 39% of the males are smokers; e) 27% had HbA1 or fructosamine lower than the maximum normal value.

CONCLUSIONS

a) The quality of medical care to diabetics in the centers analyzed is high; b) there is no "patient-type" for level of health care; c) there seems to be more therapeutic "aggressivity" among the health care workers responsible for diabetics in relation to the glucose vs other risk factors.

Variation in restorative treatment decisions: application of Receiver Operating Characteristic curve (ROC) analysis

It has been evident for many years that dentists, when planning treatment for patients, do not act in a standard manner, and previous research has shown there to be wide variations in treatment planning amongst groups of dentists. Signal detection theory and Receiver Operating Characteristic (ROC) analysis allows measurement of an observer's ability to detect a lesion, while at the same time allowing examination of how a lesion, once perceived, is judged to be in need of treatment. An ROC curve is constructed by plotting the sensitivity (or true positive rate) of decisions made, against the false positive rate (equivalent to 1-specificity) when various decision attitudes, from interventionist to non-interventionist, are held. Fifteen pairs of simulated bitewing radiographs were shown to 20 dentists, who were asked to specify, for each approximal lesion, whether or not they would place a conventional restoration. The 7200 decisions made by the dentists were validated by sectioning and microscopically examining the teeth. The mean sensitivity of the dentists' decisions, when the strictest operating thresholds were held and caries into dentine was the validating criterion, was 0.26 and the mean specificity was 0.96. ROC analysis shows that when operating at the strictest threshold, the dentists were implying that specificity was weighted as being 2.7 times more important than sensitivity. ROC analysis leads to insight into how dentists differentially weight the true and false, positive and negative, outcomes of their decisions and thus allows explanation of why two dentists would rarely make exactly the same treatment plan for one patient, and also why different treatments might be offered to two patients exhibiting the same levels of disease.

High-risk clients and mental health care management

A framework characterizing high-risk psychiatric patients by their probability of hospitalization and lengthy stay is introduced. Risk curves are then developed for each patient showing the potential impact of mental health case management on patient risk. Preliminary empirical analysis reveals that although most patients benefit from the case management intervention, some 30% of the client population may face an increase in risk of hospitalization and lengthy stay.

[A system for the clinico-immunological prognosis of infectious-inflammatory complications in planned surgery]

Postoperative infectious complications in planned surgery are a pressing problem. The preoperative condition of the patient and his immune system play an important role in their development. Fifty patients of the "risk" group were selected from the standpoint of classification of the etiological factors of secondary immunodeficiency states. Fifteen patients who had no symptoms classified as SIDS risk factors formed the control group. The immune status was examined before and on the third day after the operation in all patients of the main and control groups. Various infectious complications developed after the operation in 23 patients of the risk group. No such complications occurred in the control group. The preoperative immune status of the risk group patients differed significantly from that of the controls in 13 of 19 parameters. The patients of the main and control groups formed the instructing selection. An expert system of preoperative clinico-immunological prognostication of postoperative infectious-inflammatory complications was created on oasis of the methods of the theory of image recognition and instructing selection. The system was tested in a direct clinical experiment on 66 patients. The prognoses were correct in 89% of cases. It was thus proved that symptoms classified as SIDS risk factors influence the initial immunity status and the course of the postoperative period in planned surgery. An accurate, sensitive, and specific method for prognosticating postoperative infectious complications is suggested.

New Jersey's Medicaid waiver for acquired immunodeficiency syndrome

This article contains data from a study of New Jersey's home and community-based Medicaid waiver program for persons with symptomatic human immunodeficiency virus illness. Major findings include lower hospital costs and utilization for waiver participants compared with general Medicaid acquired immunodeficiency syndrome admissions in New Jersey. Average program expenditures were $2,400 per person per month. Based on study findings, it is evident that the waiver program is an important means of providing financial benefits and access to services and that comprehensive case management is a critical factor in assuring program quality.

Care of elderly patients with a fractured neck of femur

This survey was designed to compare the clinical management of elderly patients admitted to hospitals with a hip fracture, with the recommendations in the recent Royal College of Physicians report "Fractured Neck of Femur". The results highlight large discrepancies between the 'ideal' clinical management as recommended, and that which occurs in practice. Particular concerns include the lack of experienced medical supervision provided for patients perioperatively, the high proportion of junior anaesthetic and surgical staff performing the operation, and the widespread poor rehabilitation facilities. These findings suggest that, unless the quality of clinical care for such patients is vastly improved, the predicted exponential rise in the number of elderly people sustaining a hip fracture will create a heavy burden on scarce National Health Service resources.

Use and effectiveness of psychiatric nursing care plans

Nursing administrators require that bedside nurses should use nursing care plans, which also serve the purposes of auditors, educators and others. They are time consuming, they are not uniformly liked by bedside nurses, and they are not used with equal rigour everywhere. Their efficacy as enhancers of quality of care given has seldom been investigated and never demonstrated. In an attempt to repair this deficiency, the author documented 158 transactions between psychiatric nurses and their patients over a 5-month period. In each instance, the quality of the care given was judged and scored. Subsequently, the author determined whether nursing care plans existed and, by comparing them with the transactions, determined whether or not they had been followed. These nurses did not generally follow the care plans, though usually they thought they had. Transactions done where a nursing care plan existed were not better than those done in the absence of nursing care plans. In transactions following an existing nursing care plan, the quality of care given was judged to be lower than in those where an existing nursing care plan was not followed, a result which was statistically highly significant. These findings are discussed, and the author notes the clear implication of this study that nursing care plans are less than helpful to bedside nursing.

[BRACS--a method for cephalometric diagnosis and orthodontic treatment planning. Biometric radiographic analysis of the craniofacial skeleton]

The BRACS (the biometric radiographic analysis of the craniofacial skeleton) is a mathematically originated method for diagnosing malocclusion and planning orthodontic treatment. In the conventional cephalometrics, the measurements are to be made in an unstable reference frame without any definable direction or coordinate system. When using the BRACS, the natural reference structures can be replaced by an artificial stable reference system. The procedure is introduced in this paper.

Do dentists have sufficient information about their patients to control infection?

This study examined dentists' knowledge of infection control, what dentists say they do to control infection, and what procedures they actually take to prevent the transmission of disease. A professional actor, obviously in need of dental care and playing the part of a patient, was sent to three groups of randomly selected dentists in general practice. The dentists were uninformed subjects who were debriefed about the research immediately after their part in the experiment was completed. The study found that dentists apparently know what they should do to protect themselves from contamination. However, very few dentists discussed HIV or AIDS while taking a pretreatment history of a new patient even if that patient was perceived to belong to a high-risk group. The behavior of the dentists indicates a neglect of this important aspect of a thorough history, providing more evidence that emphasis on infection and infection control is necessary in the dental school curriculum and beyond. Unless dentists learn to fully understand what infections their patients may have, they take the chance of transmitting diseases to other patients as well as to themselves, their staff, and their families.

Nursing Model Encourages Care Planning

After examining the pitfalls of nursing care plans done in a medical model format, a system based entirely on the nursing model was developed in a 500-bed acute care hospital. By centering the format, the structure, and the education around the patient problems treated by nurses, the nurses in this hospital began to do care plans for the purpose of improving patient care rather than for compliance with the Joint Commission on Accreditation of Healthcare Organizations' regulations. The system has led to more knowledgeable nurses and a more autonomous and rewarding practice setting.

Statistical quality control in nursing homes: a key indicator to evaluate patient incontinence care

The authors provide descriptive data regarding incontinence care within the framework of statistical quality control technology. Descriptive data of patient wetness frequencies were collected for 126 incontinent patients from six nursing homes in Middle Tennessee under conditions guaranteeing that they were checked and changed on a two-hour basis. One hundred inspection subsamples were randomly selected for five incontinent-patient sample sizes: 10, 15, 20, 25, and 30 patients. The average and expected variability of patient wetness frequency was calculated for each of these subsamples. These measures help nursing homes determine if they are in compliance with state and federal regulations regarding the timeliness of incontinence care. The authors suggest how nursing home management and regulatory agencies can use statistical quality control techniques.

Misconceptions about use of case management services by the chronic mentally ill: a utilization analysis

Records of service contacts made over a six-month period by 44 chronic mentally ill patients served by a private case management agency in Washington, D.C., were analyzed to assess the accuracy of common assumptions held by mental health professionals about appropriate staff-to-patient ratios, the relationship between age and chronicity and use of services, the intensity of service use over time, and similar beliefs. The results suggest that the optimum staff-to-patient ratio is about 1 to 15, that older patients require fewer service contacts than younger patients, that patients' chronicity is not related to their extent of service use, and that patients' frequency of service use does not change over time. Patients who received services at the agency and patients who were seen alone required more service contacts than patients who were seen in the community and patients who were accompanied at their service contacts by members of their support network.