Evaluation of a mentorship program for heart transplant patients

The Heart Transplant Mentor Programme (HTMP) was initiated to augment patient care by providing patients and families with information and support from a peer perspective. We assessed program effectiveness with a pilot study of semi-structured interviews of 63% (10/16) of the mentored patients and an open-ended inquiry that rated the program on a 5-point scale (1, poor, to 5, excellent) and that selected descriptors of the program. Qualitative and quantitative analyses indicated that participants found the information and support provided by their mentors positive (3.8 and 4.0, respectively), discussion focused on medical rather than psychosocial topics, pre-transplant dissatisfaction with the program was caused by late or little mentor contact, and post-transplant dissatisfaction was attributed to difference in clinical course between mentor and patient. Although findings indicate that HTMP augments patient care, recommendations to increase patient satisfaction include earlier introduction of a mentor and individualizing mentors according to demographics and clinical course.

A Simple Quantitative FT-IR Approach for the Study of a Polymorphic Transformation Under Crystallization Slurry Conditions

The pharmaceutical compound (2R,3S)-2-([(1R)-1-[3,5-bis(trifluoromethyl)phenyl]ethyl]oxy)-3-(4-fluorophenyl)morpholine hydrochloride (denoted here as Compound X), has been found to crystallize in at least two polymorphic forms. Using only two frequencies (1009 and 1058 cm(-1)) in the infrared, a linear (R=0.998) calibration plot, consisting of the ratio of the peak absorbances plotted against polymorph concentration, was constructed. This plot allowed the quantification of binary mixtures of polymorphs ranging from <3 to approximately 100 wt% Form II in Form I. Spectra were acquired in transmission mode using mineral oil (Nujol) mull sample preparation, for reasons of compatibility with wet cake and slurry samples. The transformation of the less thermodynamically stable polymorph (Form II) to the more stable form (Form I), in stirred methyl isobutyl ketone (MIBK) slurries, was monitored spectroscopically as a function of time. Performing the experiment at various temperatures allowed the energy of activation for the process to be estimated (42 kJ/mol).

Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care

OBJECTIVE

To assess the effectiveness of three different methods of promoting secondary prevention of coronary heart disease in primary care.

DESIGN

Pragmatic, unblinded, cluster randomised controlled trial.

SETTING

Warwickshire.

SUBJECTS

21 general practices received intervention; outcome measured in 1906 patients aged 55-75 years with established coronary heart disease.

INTERVENTIONS

Audit of notes with summary feedback to primary health care team (audit group); assistance with setting up a disease register and systematic recall of patients to general practitioner (GP recall group); assistance with setting up a disease register and systematic recall of patients to a nurse led clinic (nurse recall group).

MAIN OUTCOME MEASURES

At 18 months' follow up: adequate assessment (defined) of 3 risk factors (blood pressure, cholesterol, and smoking status); prescribing of hypotensive agents, lipid lowering drugs, and antiplatelet drugs; blood pressure, serum cholesterol level, and plasma cotinine levels.

RESULTS

Adequate assessment of all 3 risk factors was much more common in the nurse and GP recall groups (85%, 76%) than the audit group (52%). The advantage in the nurse recall compared with the audit group was 33% (95% confidence interval 19% to 46%); in the GP recall group compared with the audit group 23% (10% to 36%), and in the nurse recall group compared with the GP recall group 9% (-3% to 22%). However, these differences in assessment were not reflected in clinical outcomes. Mean blood pressure (148/80, 147/81, 148/81 mm Hg), total cholesterol (5.4, 5.5, 5.5 mmol/l), and cotinine levels (% probable smokers 17%, 16%, 19%) varied little between the nurse recall, GP recall, and audit groups respectively, as did prescribing of hypotensive and lipid lowering agents. Prescribing of antiplatelet drugs was higher in the nurse recall group (85%) than the GP recall or audit groups (80%, 74%). After adjustment for baseline levels, the advantage in the nurse recall group compared with the audit group was 10% (3% to 17%), in the nurse recall group compared with the GP recall group 8% (1% to 15%) and in the GP recall group compared with the audit group 2% (-6% to 10%).

CONCLUSIONS

Setting up a register and recall system improved patient assessment at 18 months' follow up but was not consistently better than audit alone in improving treatment or risk factor levels. Understanding the reasons for this is the key next step in improving the quality of care of patients with coronary heart disease.

An assessment of cancer clinical trials vocabulary and IT infrastructure in the U.S

Twenty-three cancer research centers in the U.S. were assessed to determine data standards, vocabularies, and information infrastructure used in support of clinical trials. Eighteen of the 23 responded. Major findings were related to: 1) clinical trials infrastructure information, 2) current systems environment, 3) technical details, and 4) vocabulary and data standards. The size of the facility correlated with the quality, features and functionality of the clinical trials system (CTS). One facility had as many as 22 separate CTS. There were only 2 sites that had integrated clinical information systems (CIS) with CTS. The responses included the major vocabularies and data standards used in CTS. The majority used some automation but many also reported manual data entry. CTS had more manual entry than CIS because of regulatory reporting requirements. The assessment identified opportunities for guidance in defining vocabularies and standards for cancer clinical trial systems in the US.

Integrating primary and secondary care: the case of Christchurch South Health Centre

AIMS

To study health services utilisation linkages and methodological issues in integrating primary and secondary care services for a defined general practice population (Christchurch South Health Centre, CSHC).

METHODS

The Centre supplied national health index (NHI) linked data on date of birth, gender and community services card (CSC) status for 10,174 patients, and data on primary care. Secondary care providers supplied NHI linked data on specialist outpatients, emergency department usage for 1996 to 1998, and waiting lists. The Health Funding Authority (HFA) supplied NHI linked data on inpatient/daypatients for 1996 and 1997. Data were also obtained relating to community support services and long-term care. Rates of hospital utilisation for the Centre's population were standardised for comparison with national and Christchurch figures using age, gender and CSCs. Overall per capita expenditure was calculated for this population.

RESULTS

Patients with CSCs constituted 31.2% of the practice population, but generated 60.8% of bed-days. Patients with high use health cards (HUHCs) constituted 8.6% of the population, but generated 42.4% of bed-days. This group was at high risk of hospitalisation over a wide range of disease categories. Standardised rates of hospital utilisation were significantly lower for the Centre's older patients, especially for bed-days, than both national and Christchurch figures. Only a small proportion of referrals to specialist outpatients, 28.2% in 1998, was from the Centre's general practitioners (GPs), the remainder being generated internally within the specialist services. The overall expenditure per capita on the Centre's population was $1012, which was substantially less than expected in comparison with national figures.

CONCLUSION

The study demonstrates the importance of primary care factors in the utilisation of secondary care, especially acute hospitalisation in older patients. This needs further study as it could provide important insights into ways of reducing acute admissions. If there is to be more effective management of the primary/secondary care interface, more research and development effort is needed into the characteristics of patients at high risk of referral and admission, and how inappropriate secondary care can be averted.

Mentorship programs for transplant patients

The concept of mentoring has been used successfully in numerous settings, but only in the past decade have mentoring programs been used with organ transplant recipients. This paper describes how the Toronto Multi Organ Transplant Mentor Programme works, is administered, augments patient care, is evaluated, and has been adapted to meet the needs of various transplant patient populations.

Reassessment of the corneal endothelial cell organisation in children

AIM

To assess uniformity of the corneal endothelial cell mosaic in children.

METHODS

36 healthy children (5-11 years old, 16 boys, 20 girls) were assessed by specular microscopy. Endothelial cell density (ECD) was calculated from measured cell areas, and the number of sides/cell noted.

RESULTS

Average values for ECD and cell areas were 3987 cells/mm(2) (95% CI 3806 to 4168 cells/mm(2)) and 278 (SD 85) mm(2) respectively, with normal distribution (COV 28. 2%, range 17.4 to 39.2%) and with the average percentage of six sided cells being 66.6% (8.8%). Cell area was positively correlated to number of cell sides (p <0.01, r(2)=0.993), but the percentage of six sided cells was negatively correlated to ECD (p <0.01, r=0.493).

CONCLUSION

A high ECD occurs in children, but this does not mean there is a high percentage of "hexagons".

Laboratory expenditure in Pegasus Medical Group: a comparison of high and low users of laboratory tests with academics

AIMS

To determine, through the use of clinical vignettes, whether low and high cost users of laboratory tests in Pegasus Medical Group (Pegasus) differed in their choice of laboratory tests from academics as a means of further investigating issues relating to quality and cost in laboratory testing.

METHODS

Seven clinical vignettes were drawn up and sent to 30 selected members in Pegasus whose actual laboratory expenditure per consultation ranged from a mean of $2.3 in a low cost group (15 members) to $12.2 in a high cost group (15 members). The vignettes were also sent to 15 general practitioner academics. Respondents were requested to complete a laboratory form as to which tests they would use for each individual scenario. The answers were analysed for overall cost as well as numbers of laboratory tests requested.

RESULTS

There were 14 academic responses and 13 each from the bottom and top laboratory users. Overall results for the seven vignette cases showed that low cost laboratory users would spend a total of $176.3, the academics $188.8, and the high cost users $219.5 on the cases. The mean per case costs were $25.2, $27.0 and $31.4 respectively. There was a clear tendency for high volume users of tests in each vignette to be high in others suggesting that doctor rather than patient factors were the main explanation of the variation.

CONCLUSIONS

Clinical vignettes do not appear to be a useful strategy in clarifying issues related to quality and cost in laboratory utilisation. Test ordering behaviour appears, from the international literature and this study, to be determined more by personal doctor factors than by objective evidence and clinical need. Further work is needed to clarify the relationship between quality and the wide variation observed in utilisation and expenditure.

Emerging clinical governance: developments in independent practitioner associations in New Zealand

AIMS

To document and analyse the development of independent practitioner associations and similar groups in New Zealand.

METHODS

A questionnaire was sent to the 30 independent practitioner associations in August 1998 and followed-up by a number of reminders.

RESULTS

The 28 respondents (93%) represent 97% coverage of the estimated membership of independent practitioner associations and similar groups. Membership of the 28 responding organisations ranged between seven and 340, with an average of 74 members and a total of 132 employed staff. Twenty-one had appointed a chief executive officer or general manager. The respondents' most important goals were "achieving better health outcomes for patients" and "making better use of primary care resources". They reported almost total implementation of computerised age/sex registers in their practices. There was strong support for independent practitioner associations to manage the clinical activity of members, to move from historical to equitable, needs-based funding and for formal patient enrolment. The majority of respondents supported integrated and capitated primary care budgets but few supported capitated budgets for separate general medical services, laboratory and pharmaceutical services. Important recent initiatives include a wide range of integration projects and increasing involvement of local communities.

CONCLUSION

Independent practitioner associations have made significant progress in increasing membership levels, in establishing a framework for managing clinical activity of members and in developing their infrastructure, including information systems. They have established a wide range of new relationships within primary care, with their communities and with primary and secondary care providers. In managing increasing amounts of public money to achieve public goals, these groups may be developing a new model of clinical governance, which could be of international importance.

The success of an integrated care programme for patients with ischaemic heart disease: the practice nurses' perspective of SHIP

Follow-up care of patients with angina and myocardial infarction after hospital discharge is known to be suboptimal across the UK. The employment of cardiac liaison nurses ensured timely notification of hospital discharge and good communication of each patient's current and planned care. The direct ongoing support of the liaison nurse was valued by more practice nurses than educational support meetings and the initial counselling skills course. The most important factor which enabled practice nurses to expand their role to provide post-hospital follow-up care was the support of the doctors in the practice. After the conclusion of the Southampton Heart Integrated Care Project (SHIP) and the withdrawal of cardiac liaison nurses, the lack of hospital discharge notification was the most important reason for practice nurses discontinuing follow-up care.

Neisseria canis infection: a case report

The third case report, which is the first in Australia, of human infection with Neisseria canis is documented. This is the first case report in which the pathogenicity of this organism for humans is unequivocally demonstrated.

Verbal communication: what do critical care nurses say to their unconscious or sedated patients?

The importance of using verbal communication in the care of critically ill patients has long been known. Both qualitative and quantitative studies have presented evidence of the benefits of effective communication. This non-participant observational study aimed to explore how much and what types of verbal communication critical care nurses use when caring for unconscious or sedated patients. Sixteen critical care nurses were observed in 4-hour episodes and their verbal communication was transcribed and timed at source. Seven categories of verbal communication and a 'core concept' emerged on analysis of the raw data. Medical investigations/interventions performed on the patients increased the amount of communication used. The participants in this study were found to use a greater variety and amount of verbal communication than participants in other studies. The findings of this study highlight the need for formal support systems and continued education for nurses about the benefits of verbal communication.

Prostacyclin synthase expression is decreased in lungs from patients with severe pulmonary hypertension

Prostacyclin is a powerful vasodilator and inhibits platelet adhesion and cell growth. We hypothesized that a decrease in expression of the critical enzyme PGI2 synthase (PGI2-S) in the lung may represent an important manifestation of pulmonary endothelial dysfunction in severe pulmonary hypertension (PH). Immunohistochemistry and Western blot analysis were used to assess lung PGI2-S protein expression, and in situ hybridization was used to assess PGI2-S mRNA expression. In the normal pulmonary circulation (n = 7), PGI2-S was expressed in 48% of small, 67% of medium, and 76% of large pulmonary arteries as assessed by immunohistochemistry. PPH (n = 12), cirrhosis-associated (n = 4) and HIV-associated PH (n = 2) lungs exhibited a marked reduction in PGI2-S expression, involving all size ranges of pulmonary arteries. Vessels with concentric lesions showed complete lack of PGI2-S expression. Congenital heart (n = 4) and CREST (n = 2) cases exhibited a more variable immunohistological pattern of PGI2-S expression. These results were complemented by in situ hybridization and Western blots of representative lung samples. We conclude that the different sizes of the pulmonary arteries express PGI2-S differently and that the loss of expression of PGI2-S represents one of the phenotypic alterations present in the pulmonary endothelial cells in severe PH.

Do people who apply sunscreens, re-apply them?

Little is known about Australians' practices regarding sunscreen re-application, yet it is routinely advised and has recently been shown to increase the protective efficacy of sunscreens. A baseline survey of sunscreen application and re-application behaviour was therefore conducted in a Queensland community using a standard self-administered questionnaire. Other sun protection methods were also assessed. Of a total of 669 adult respondents, 76% reported using sunscreen and of those, 61% reported re-applying sunscreen. Significantly more women (66%) than men (55%) reported re-applying sunscreen and re-application was inversely related to age (79% of those aged less than 45, 57% of those 45-59 years old and 46% of those over 60 years). Increased rates of re-application were reported during times of increased sun exposure, as well as by those with greater knowledge of the benefits of sunscreen re-application. A recent personal history of non-melanoma skin cancer did not lead to improved rates of sunscreen application, sunscreen re-application, or most forms of physical sun protection.

An evaluation of pharmaceutical management and budget holding in Pegasus Medical Group

AIMS

To describe and evaluate pharmaceutical management, including budget holding, in Pegasus Medical Group (Pegasus), to determine savings being achieved, to analyse variation in prescribing behaviour and to compare the findings with national and international experience.

METHODS

Trends in pharmaceutical expenditure of the 150 Pegasus' 208 members who had a continuous prescribing record for the three years ending December 1996 were compared with national trends. Expenditure per member, per consultation and per item were also analysed.

RESULTS

Pegasus has implemented a comprehensive and classical pharmaceutical management strategy. This includes active personalised feedback, information sharing, peer review groups and information system development, all within an incentive framework of retained savings for new services. Although about 5% savings of total pharmaceutical expenditure were identified by the above method, the real level may be higher. Wide variation between members in their prescribing behaviour was explained almost entirely by the volume rather than the price of the drugs prescribed. Targeting of the volume issue is therefore likely to have a much more significant effect in reducing inappropriate variation.

CONCLUSION

The results indicate that the achievements of Pegasus, as for other independent practitioner associations, go far beyond the modest level of pharmaceutical savings achieved. These include the development of a substantial infrastructure, peer review processes, new internal and external relationships and accountability for the management of both quality and cost in what may be styled clinical governance. Such achievements put Pegasus and other independent practitioner associations into a strong position to take on new initiatives including integration with secondary care.

Do people who apply sunscreens, re-apply them?

Little is known about Australians' practices regarding sunscreen re-application, yet it is routinely advised and has recently been shown to increase the protective efficacy of sunscreens. A baseline survey of sunscreen application and re-application behaviour was therefore conducted in a Queensland community using a standard self-administered questionnaire. Other sun protection methods were also assessed. Of a total of 669 adult respondents, 76% reported using sunscreen and of those, 61% reported re-applying sunscreen. Significantly more women (66%) than men (55%) reported re-applying sunscreen and re-application was inversely related to age (79% of those aged less than 45, 57% of those 45-59 years old and 46% of those over 60 years). Increased rates of re-application were reported during times of increased sun exposure, as well as by those with greater knowledge of the benefits of sunscreen re-application. A recent personal history of non-melanoma skin cancer did not lead to improved rates of sunscreen application, sunscreen re-application, or most forms of physical sun protection.

Minority enrichment programs at the New Jersey Medical School: 26 years in review

In 1971 the New Jersey Medical School formed a task force to address the training of physicians from minority and disadvantaged backgrounds, and in 1972 the Students for Medicine Program (SMP) was launched. The program, one of the first of its kind, provided previews of college science courses to help minority students develop their noncognitive skills and make the transition to medical school. The school has also established other minority programs. The programs have been designed to form a health careers pipeline for college-bound students, beginning in the eighth grade. Grade-specific summer experiences, as well as year-round monthly workshops, are offered to all participants. The workshops for pre-college and college students and their parents are designed to strengthen students' academic skills, address issues such as self-esteem, provide exposure to health professions, and increase parents' knowledge and involvement. From 1972 to 1998, there had been 1,722 participants in the pre-college, 1,875 in the college, and 683 in the prematriculation programs, respectively. They were from the inner city, most of them African American, but with a growing number of Hispanics. From 1987 to 1994, 36% of the SMP participants entered health professions schools. In 1996, the medical school created the New Jersey Partnership for Health Professions Education, a collaboration of high schools, universities, community-based organizations, the federal government, and the health professions schools. It works to strengthen the medical school's "pipeline" for underrepresented minority students while eliminating competition among programs for the same students and simultaneously developing a larger pool.

Minority enrichment programs at the New Jersey Medical School: 26 years in review

In 1971 the New Jersey Medical School formed a task force to address the training of physicians from minority and disadvantaged backgrounds, and in 1972 the Students for Medicine Program (SMP) was launched. The program, one of the first of its kind, provided previews of college science courses to help minority students develop their noncognitive skills and make the transition to medical school. The school has also established other minority programs. The programs have been designed to form a health careers pipeline for college-bound students, beginning in the eighth grade. Grade-specific summer experiences, as well as year-round monthly workshops, are offered to all participants. The workshops for pre-college and college students and their parents are designed to strengthen students' academic skills, address issues such as self-esteem, provide exposure to health professions, and increase parents' knowledge and involvement. From 1972 to 1998, there had been 1,722 participants in the pre-college, 1,875 in the college, and 683 in the prematriculation programs, respectively. They were from the inner city, most of them African American, but with a growing number of Hispanics. From 1987 to 1994, 36% of the SMP participants entered health professions schools. In 1996, the medical school created the New Jersey Partnership for Health Professions Education, a collaboration of high schools, universities, community-based organizations, the federal government, and the health professions schools. It works to strengthen the medical school's "pipeline" for underrepresented minority students while eliminating competition among programs for the same students and simultaneously developing a larger pool.