Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

OBJECTIVES

To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.

DESIGN

Cost consequences study alongside randomised controlled trial.

SETTING

Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.

PARTICIPANTS

3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.

MAIN OUTCOME MEASURES

NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.

RESULTS

Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).

CONCLUSION

The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.

Design and performance of a multicentre, randomized controlled trial of teleconsulting

We have designed and performed a multicentre, randomized controlled trial of teleconsulting. The trial investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing as an alternative to general practitioner referral to a hospital specialist. The participating general practitioners referred a total of 3170 patients who satisfied the entry criteria. Of these, 1040 (33%) failed to provide consent or otherwise refused to participate in the trial. Of the patients recruited to the trial, a total of 1902 (91%) completed and returned the baseline questionnaire. Although the trial was successful in recruiting sufficient patients and in obtaining high questionnaire response rates, the findings will require careful interpretation to take account of the limits which the protocol placed on the ability of general practitioners to select patients for referral.

Mood disorders: diagnosis, treatment, and support from a patient perspective

The National Depressive and Manic-Depressive Association (National DMDA) is the largest patient-directed, illness-specific organization in the United States, representing the millions of people living with mood disorders. Recent National DMDA surveys have shown that people with mood disorders often have incorrect information about their illnesses, that misdiagnoses are frequent, that a significant physician/patient communication gap exists, and that noncompliance is widespread. For optimal recovery to occur, it is important that individuals receive correct information about their symptoms and treatments, that physicians and other healthcare providers understand mood disorders from a patient perspective, and that doctors and patients communicate fully throughout the course of treatment about symptoms, side effects, and other concerns. National DMDA plays an important role in the management of mood disorders by urging those who are undiagnosed or untreated to seek treatment; by providing accurate, easy-to-understand information; and by facilitating support groups in which patients and their families can discuss treatment and management of their illnesses. The organization encourages patients to play active roles in their treatment plans and to attend support groups, which have been shown to increase patient compliance and decrease the incidence of psychiatric hospitalization. According to the US Surgeon General, stigma is the number one barrier to mental health care, and National DMDA's evidence supports this. National DMDA works to combat stigma with education, advocacy, and patient self-help. Increased awareness and openness about mood disorders can lead to increased acceptance, which, in turn, can lead to more timely diagnosis and treatment.

Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial

BACKGROUND

The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral.

METHODS

Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat.

FINDINGS

More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites.

INTERPRETATION

The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.

Assessing the impact of Cry1Ab-expressing corn pollen on monarch butterfly larvae in field studies

Survival and growth of monarch larvae, Danaus plexippus (L.), after exposure to either Cry1Ab-expressing pollen from three Bacillus thuringiensis (Bt) corn (Zea mays L.) events differing in toxin expression or to the insecticide, lambda-cyhalothrin, were examined in field studies. First instars exposed to low doses ( approximately 22 grains per cm(2)) of event-176 pollen gained 18% less weight than those exposed to Bt11 or Mon810 pollen after a 5-day exposure period. Larvae exposed to 67 pollen grains per cm(2) on milkweed leaves from within an event-176 field exhibited 60% lower survivorship and 42% less weight gain compared with those exposed to leaves from outside the field. In contrast, Bt11 pollen had no effect on growth to adulthood or survival of first or third instars exposed for 5 days to approximately 55 and 97 pollen grains per cm(2), respectively. Similarly, no differences in larval survivorship were observed after a 4-day exposure period to leaves with 504-586 (within fields) or 18-22 (outside the field) pollen grains per cm(2) collected from Bt11 and non-Bt sweet-corn fields. However, survivorship and weight gain were drastically reduced in non-Bt fields treated with lambda-cyhalothrin. The effects of Bt11 and Mon810 pollen on the survivorship of larvae feeding 14 to 22 days on milkweeds in fields were negligible. Further studies should examine the lifetime and reproductive impact of Bt11 and Mon810 pollen on monarchs after long-term exposure to naturally deposited pollen.

IL-1H, an interleukin 1-related protein that binds IL-18 receptor/IL-1Rrp

IL-18, or IGIF (interferon-gamma inducing factor), is an IL-1-related, pro-inflammatory cytokine, which plays a pivotal role in systemic and local inflammation. We have identified and characterized IL-1H, a novel IL-1-related molecule. IL-1H appears to be expressed in most tissues with relatively high levels in testis, thymus and uterus. The IL-1H transcripts were stimulated by phorbol ester (PMA) in human cell lines (A431, THP-1 and KG-1) and peripheral blood mononuclear cells (HPBMC) and dendritic cells (NHDC). The protein sequence of IL-1H is mostly related to IL-1ra with a similarity of 36%. A short form of IL-1H was identified, and lacks a 40-amino acid segment in the amino-terminal region of the protein. When expressed in mammalian cells, two secreted polypeptides of IL-1H were identified: an uncleaved and a cleaved form starting with amino acid Val-46. Furthermore, IL-1H binds the IL-18 receptor, but not the IL-1 receptor. These findings suggest that IL-1H may be another ligand for the IL-18 receptor and a new player in the inflammatory and immune responses mediated by the IL-18/IL-18R axis.

A teaching videotape for the assessment of essential tremor

Teaching videotapes, developed to aid in the evaluation of several movement disorders, have not been used in essential tremor research. As part of the Washington Heights-Inwood Genetic Study of Essential Tremor (WHIGET), we developed a reliable and valid tremor rating scale. Because this rating scale is currently being used by investigators at other centers, we developed a teaching videotape to aid in the consistent application of this scale.

OBJECTIVE

To develop a teaching videotape for a revised version of the WHIGET Tremor Rating Scale and to assess the interrater agreement among raters who used this videotape to rate tremor.

METHODS

The revised WHIGET Tremor Rating Scale was used to rate action tremor from 0 to 4 during six tests: arm extension, pouring, drinking, using a spoon, finger-to-nose, and drawing spirals. A 22-minute teaching videotape was developed that includes a 29-item educational section and a self-assessment section consisting of 20 examples of tremor ratings chosen by the two WHIGET study neurologists. Eight raters, including senior movement disorder specialists, movement disorder fellows, general neurologists, and a movement disorder nurse practitioner, independently viewed the videotape and rated tremor during the self-assessment section. Interobserver reliability was assessed with weighted kappa statistics (kappa(w)).

RESULTS

Eight raters each rated 20 items (160 ratings total). Total kappa(w) was 0.97 (nearly perfect agreement). Interrater reliability was as follows: kappa(w) = 0.99 (movement disorder specialists), kappa(w) = 0.98 (movement disorder fellows), and kappa(w) = 0.97 (general neurologists); all kappa(w) were nearly perfect.

CONCLUSIONS

This teaching videotape may be used to improve the uniform application of the revised WHIGET Tremor Rating Scale by raters with various levels of experience in movement disorders.

Probenecid-inhibitable efflux transport of valproic acid in the brain parenchymal cells of rabbits: a microdialysis study

Delivery of valproic acid (VPA) to the human brain is relatively inefficient as reflected by a low brain-to-unbound plasma concentration ratio (< or =0.5) at steady state. Previous pharmacokinetic studies suggested that the unfavorable brain-to-plasma gradient is maintained by coupled efflux transport processes at both the brain parenchymal cells and blood-brain barrier (BBB); one or both of the efflux transporters are inhibitable by probenecid. The present study in rabbits utilized microdialysis to measure drug concentration in the brain extracellular fluid (ECF) of the cerebral cortex during steady-state i.v. infusion with VPA alone or with VPA plus probenecid. Probenecid co-infusion elevated VPA concentration in the brain tissue surrounding the tip of the microdialysis probe to a greater extent than in the ECF (230% versus 47%). Brain intracellular compartment (ICC) concentration was estimated. In control rabbits, the ICC concentration was 2.8+/-0.28 times higher than the ECF concentration. Probenecid co-infusion elevated the ICC-to-ECF concentration ratio to 4.2+/-0.44, which confirms the existence of an efflux transport system in brain parenchymal cells. The ECF-to-unbound plasma concentration ratio was well below unity (0.029), indicating an uphill efflux transport of VPA across the BBB. Co-infusion of probenecid did not have a significant effect on VPA efflux at the BBB as evidenced by a minimal change in the ECF-to-unbound plasma concentration ratio. This study suggests the presence of distinctly different organic anion transporters for the efflux of VPA at the parenchymal cells and capillary endothelium in the brain.

Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire

OBJECTIVE

Bipolar spectrum disorders, which include bipolar I, bipolar II, and bipolar disorder not otherwise specified, frequently go unrecognized, undiagnosed, and untreated. This report describes the validation of a new brief self-report screening instrument for bipolar spectrum disorders called the Mood Disorder Questionnaire.

METHOD

A total of 198 patients attending five outpatient clinics that primarily treat patients with mood disorders completed the Mood Disorder Questionnaire. A research professional, blind to the Mood Disorder Questionnaire results, conducted a telephone research diagnostic interview by means of the bipolar module of the Structured Clinical Interview for DSM-IV.

RESULTS

A Mood Disorder Questionnaire screening score of 7 or more items yielded good sensitivity (0.73) and very good specificity (0.90).

CONCLUSIONS

The Mood Disorder Questionnaire is a useful screening instrument for bipolar spectrum disorder in a psychiatric outpatient population.

A low-cost approach to public health education using multimedia packages

The effect of health education programmes depends on the number of people exposed to the messages, as well as the method and style in which the information is transmitted. We conducted a pilot project to encourage healthier lifestyles by presenting culturally sensitive information using a variety of media. Material intended to provoke discussion was shared with a range of audiences in Barbados and Montserrat in the West Indies by a series of lecture discussions, which were videorecorded for local television and sound recorded for local radio. The lecture was also disseminated by newspaper articles, a special magazine and by publication on the Internet. The aim of the project was to achieve maximum effect for minimum effort, thus making optimum use of resources. The feedback obtained at the lecture discussions and in response to the radio broadcasts and newspaper articles provided a needs assessment on which to base a definitive programme, and confirmed that radio and television are the most effective media for health education.

Managing pre-examination stress through remote counselling using a session script from a 'sentinel subject'

Twenty-five members of a class of 45 medical students preparing for final examinations were voluntary participants in a pre-examination stress-control exercise conducted four weeks before the start of examinations. The students completed short questionnaires before and after reading the typewritten script of a counselling session of a member of their class (the sentinel subject). In the pre-script questionnaires, 50% of the men and 35% of the women reported a high level of stress. On the post-script questionnaire, 68% identified with the subject being counselled. Only four persons (16%) reported a reduction in stress after reading the script and one person recorded an increase in stress. Seventy-two per cent of respondents (40% of students) indicated that they would use counselling services if they were available. The present study suggests that some form of counselling could be usefully included in distance education modules. The provision of counselling services before examinations may prevent failure. The remote approach by sentinel subject script is an inexpensive method of providing such a service.

Low-cost video-films in the teaching of undergraduate and postgraduate medical students

The high cost of producing good-quality video-films for teaching has hindered the use of this method, which has been shown to improve significantly the efficiency of teaching and the retention of knowledge. During the last five years, a series of short video-films has been produced using inexpensive video-cameras and home video-recording and editing equipment. A variety of techniques were developed to allow recording of lecture presentations, while using the equipment as a teaching aid, without the need for technical staff. The positioning of the camera, the monitor, the slide projector and lighting were critical to the productions. Similar productions at low cost were obtained from recordings of operating theatre sessions, tutorials and clinical ward rounds. A survey of students exposed to teaching with video-film as part of a lecture presentation confirmed that the subject matter being taught was more easily understood and enjoyable and generated more discussions on than other forms of teaching.

Patient determinants of mental health interventions in primary care

BACKGROUND

A large proportion of a general practitioner's (GP's) caseload comprises patients with mental health problems. It is important to ensure that care is provided appropriately, on the basis of clinical need. It is therefore necessary to investigate the determinants of the use of mental health care in the primary care sector and, in particular, to identify any non-clinical characteristics of patients that affect the likelihood of their receiving appropriate care.

AIM

To identify and compare the influence of non-clinical patient factors on GPs' acknowledgement of mental problems and on their provision of mental health care.

METHOD

Cross sectional study of adults aged 16 to 65 years old (n = 802) attending one of eight practices (20 GPs in total) in inner west London.

RESULTS

Multivariable analysis showed that the combination of factors that best predict GPs' acknowledgement of the presence of mental problems are general health questionnaire (GHQ) scores (odds ratio [OR] = 1.10 per unit increase in score, 95% confidence interval [CI] = 1.07 to 1.13), previous mental symptoms (OR = 7.5, 95% CI = 4.3 to 12.9), increasing age (OR = 1.03 per one-year increase, 95% CI = 1.01 to 1.04) and physical health status (OR = 0.98 per unit increase in short form-36 (SF-36) score, 95% CI = 0.96 to 1.00). Multivariable analysis showed that the combination of factors that best predict intervention (prescription for psychotropic medication; return visit to GP; referral to psychiatric inpatients/outpatients; referral to other [specified] health professionals, or social services) are previous symptoms (OR = 7.4, 95% CI = 3.8 to 14.4), white ethnic group (OR = 2.2, 95% CI 0.9 to 5.5); and not owning a property (OR = 2.1, 95% CI = 1.1 to 4.0). Life events influenced intervention only in the presence of low GHQ scores (OR = 8.1, 95% CI = 2.7 to 24.0).

CONCLUSIONS

Mental problems are common in primary care and their acknowledgement is a necessary but not a sufficient condition for intervention. Our results show that GPs' decisions about mental health interventions can be influenced by non-clinical patient factors, regardless of patients' clinical needs. The results suggest that current practice may not always be equitable, and point to the need for better understanding of the basis of these potential inequalities and for focused training.

Aprotinin in the management of life-threatening bleeding during extracorporeal life support

Contact with the synthetic surfaces of an extracorporeal circuit induces alterations in vascular components, derangements of the coagulation cascade and a systemic inflammatory response. Aprotinin reduces intraoperative and postoperative bleeding in adults undergoing cardiopulmonary bypass; however, trials in children have not had similar favorable results. While there have been some anecdotal reports, there have been no prospective clinical trials exploring the utility of aprotinin in the prevention of or as a therapy for bleeding while on extracorporeal life support (ECLS). We present a case series on our experience utilizing aprotinin for the treatment of life-threatening bleeding during ECLS. The combination of a loading dose followed by a continuous infusion resulted in significant reduction in blood loss and blood product utilization. This suggests that aprotinin may have clinical efficacy in the management of massive blood loss while on ECLS; however, larger controlled trials will be essential to determine the efficacy and appropriate dosing regimens before widespread use in ECLS can be advocated.

Longitudinal risk of std acquisition in adolescent girls using a generalized estimating equations model

Background: To date, few studies have used a longitudinal approach in examining risk factors for STD acquisition in teenage girls. In the present study, we examined risk of STD acquisition in adolescent girls over a three-year period using longitudinal analyses.Methods: One hundred and seventy-four girls between the ages of 12 and 16 (mean age = 14.5) participated in a longitudinal study of adolescent romantic relationships. The racial composition of the subject pool was 80% African-American and 20% Caucasian. These girls were followed for three years at six-month intervals. By the end of the study, 127 of the girls were sexually experienced, and thus, were included in the analyses regarding risk for STDs. The risk for history of STD was evaluated using a generalized estimating equations (GEE) model, which allows for the inclusion of data from subjects with missing visits. The following independent variables were entered into the model: age, race, screening IQ score, qualitative cognitive functioning, perceptions of STD prevalence among female friends, and whether a condom was used at last intercourse. Additional independent variables included number of lifetime partners (4 or more lifetime partners, 2 to 3 lifetime partners, only one partner) and age of sexual debut (less than 14 years, 14-16 years, and 17 years and older), five factors from the Family Environment Scale, and three types of parental monitoring (direct, direct when with peers, and indirect).Results: The results of the longitudinal (GEE) model indicated that having a history of an STD was significantly related to a younger age of sexual debut (p <.01), having more partners (p <.0001), being African-American (p =. 01), and having a lower screening IQ score (p <.01).Conclusions: These results suggest that risk of STD is associated with both modifiable and non-modifiable variables. Race and intellectual functioning independently contributed to STD risk, stressing the importance of utilizing prevention programs that are culturally and developmentally specific. For example, less intelligent girls may need to have information presented in a more concrete manner, with a focus on the present rather than the future. The targets of these prevention programs should continue to emphasize delaying initiation, as well as partner selection. Finally, the fact that variables for STD acquisition in this longitudinal model are comparable to previous cross-sectional studies of STD acquisition suggests that these are potent predictors of risk.