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Maria ARJ, Serra H, Castro MG, Heleno B. Telemedicine as a tool for continuing medical education. Fam Pract 2023; 40:569-574. [PMID: 37579324 PMCID: PMC10667068 DOI: 10.1093/fampra/cmad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND There is a growing interest in the use of digital technologies to foster learning in the health professions, along with the drive to expand teleconsultations arising from the COVID-19 pandemic. This study aims to explore whether telemedicine between levels of care can act as continuous medical education (CME) tool for general practitioners (GPs) and hospital consultants at the referral cardiology department. METHODS This qualitative study was embedded in an organizational case study of the introduction of a new service model in the Portuguese health system. Semi-structured interviews were audio-recorded and pseudonymized. The transcribed interviews were stored, coded, and content analysis was performed in MAXQDA. RESULTS A total of 11 physicians were interviewed. GPs and cardiologists recognized that telemedicine between levels of care could act as a CME tool. Although they departed with different expectations, telemedicine helped them collaborate as a multidisciplinary team, exchanging feedback about clinical decisions, and constructing knowledge collaboratively. Telemedicine also supplemented existing learning meetings. The consequences of technology adoption may be viewed as a result of the actors involved (including the technology itself), characteristics of the context (including the organization), and an interaction between such factors. CONCLUSION Teleconsultations can be a learning opportunity for the health professionals involved. Our findings suggest that, in the context of the Portuguese health system, telemedicine as a CME tool helped to build multidisciplinary teams which exchanged feedback and constructed shared knowledge to improve patients' outcomes. It also helped to identify practice-changing contents to be included in face-to-face educational meetings.
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Affiliation(s)
- Ana Rita J Maria
- Regional Health Administration of Lisbon and Tagus Valley; Comprehensive Health Research Centre (CHRC), Nova Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Helena Serra
- Interdisciplinary Centre of Social Sciences (CICS. NOVA), NOVA School of Social Sciences and Humanities | Faculdade de Ciências Sociais e Humanas, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Maria G Castro
- Cardiology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - Bruno Heleno
- Regional Health Administration of Lisbon and Tagus Valley; Comprehensive Health Research Centre (CHRC), Nova Medical School | Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
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[Virtual consultations in Traumatology and Orthopaedic Surgery]. Semergen 2021; 47:305-314. [PMID: 34112593 DOI: 10.1016/j.semerg.2021.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 01/30/2021] [Accepted: 03/17/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The objective of this study is to analyse the current system of virtual consultations between the levels of Primary and Specialised Care in the field of Traumatology and Orthopaedic Surgery (TOS) in our healthcare area. MATERIAL AND METHOD A retrospective observational study was carried out on 90 consecutive patients who had a non-face-to-face consultation between 3 January 2017 and 10 February 2017 and subsequently a face-to-face consultation. All the patients belonged to the same healthcare area attached to the Nuestra Señora de Candelaria University Hospital. The data on the diagnostic orientation, medical history provided and complementary tests were evaluated by 2 observers, one with training in Family and Community Medicine and the other with specialised training in TOS, and compared with those obtained in the final face-to-face assessment. RESULTS The results showed a low inter-judge agreement regarding the diagnostic orientation, anamnesis, exploration and complementary tests provided in the virtual consultation request. It was considered that only 59% for one observer (Family and Community Medicine) and 47.7% for the other (specialised care) had sufficient information for decision-making. Furthermore, 35.2% required more than one face-to-face assessment consultation until diagnosis and in 45.5% it was necessary to request new complementary tests. In 30.7%, there was no concordance in the suggested and final diagnosis. In 51.9%, no therapeutic action other than that carried out by Primary Care was carried out and 34.1% of the patients were referred to the Rehabilitation department. CONCLUSIONS The current model of virtual consultations in TOS does not seem adequate to respond to this new healthcare model. The number of unnecessary referrals is very high despite the previous virtual assessment by a specialist in TOS. The Family and Community Medicine specialist should have more diagnostic resources and coordination between Primary and Specialised Care is necessary to determine, in the area of TOS, the type of consultations and conditions for which this system should be implemented to obtain adequate coordination and improve communication between both levels of care.
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Expert Reliability in Legal Proceedings: "Eeny, Meeny, Miny, Moe, With Which Expert Should We Go?". Sci Justice 2020; 61:37-46. [PMID: 33357826 DOI: 10.1016/j.scijus.2020.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/07/2020] [Accepted: 09/20/2020] [Indexed: 11/21/2022]
Abstract
Between Expert Reliability refers to the extent to which different experts examining identical evidence make the same observations and reach the same conclusions. Some areas of expert decision making have been shown to entail questions with relatively low Between Expert Reliability, but the disagreement between experts is not always communicated to the legal actors forming decisions on the basis of the expert evidence. In this paper, we discuss the issues of Between Expert Reliability in legal proceedings, using forensic age estimations as a case study. Across national as well international jurisdictions, there is large variation in which experts are hired to conduct age estimations as well as the methods they use. Simultaneously, age estimations can be fully decisive for outcomes e.g. in asylum law and criminal law. Using datasets obtained from the Swedish legal context, we identify that radiologists and odontologists examining knees or teeth images to estimate age seem to disagree within their own disciplines (radiologist 1 v. radiologist 2 or odontologist 1 v. odontologist 2) as well as across different disciplines (radiologist v. odontologist) relatively often. This may have large implications e.g. in cases where only one expert from the respective field is involved. The paper discusses appropriate ways for legal actors to deal with the possibility of lacking Between Expert Reliability. This is indeed a challenging task provided that legal actors are legal experts but not necessarily scientific experts.
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Investigating whether shared video-based consultations with patients, oncologists, and GPs can benefit patient-centred cancer care: a qualitative study. BJGP Open 2020; 4:bjgpopen20X101023. [PMID: 32238390 PMCID: PMC7330209 DOI: 10.3399/bjgpopen20x101023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/29/2019] [Indexed: 12/12/2022] Open
Abstract
Background Guidelines have proposed that GPs should have a central role as coordinators of care and support patients with cancer during all stages of treatment, follow-up, and rehabilitation. Multidisciplinary video consultation involving the patient with cancer, the oncologist, and the GP may help to define roles and tasks, and this resulting clarity may enable greater support for patients with cancer. Aim To explore the consultation structure, content, and task clarification when a GP and an oncologist are attending a video consultation with a patient with cancer. Design & setting A qualitative study took place in the Region of Southern Denmark to investigate multidisciplinary video consultations, based on thematic analysis. Method Recordings of 12 video consultations were analysed using the framework method. A combined deductive and inductive approach was undertaken. The deductive themes were selected based on a consultation guide given to the doctors before the consultations. Results The study identified 15 themes, which were grouped into the following three categories: the implications of sharing a consultation; consultation structure; and health concerns. Conclusion Multidisciplinary video-based consultations with a patient and two health professionals succeeded in having a patient-centred communication style. In clarifying tasks between the GP and oncologist to support the patient, work-related issues and professional support for psychosocial challenges were always a task for the GP. Dissemination of this first-line evidence may improve acceptability among medical specialists and help assist GPs in supporting patients with cancer. However, focus on the involvement of relatives should be emphasised.
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van den Bogaart EHA, Spreeuwenberg MD, Kroese MEAL, van den Boogaart MW, Boymans TAEJ, Ruwaard D. Referral decisions and its predictors related to orthopaedic care. A retrospective study in a novel primary care setting. PLoS One 2020; 15:e0227863. [PMID: 31971964 PMCID: PMC6977750 DOI: 10.1371/journal.pone.0227863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/31/2019] [Indexed: 12/05/2022] Open
Abstract
Due to the ageing population, the prevalence of musculoskeletal disorders will continue to rise, as well as healthcare expenditure. To overcome these increasing expenditures, integration of orthopaedic care should be stimulated. The Primary Care Plus (PC+) intervention aimed to achieve this by facilitating collaboration between primary care and the hospital, in which specialised medical care is shifted to a primary care setting. The present study aims to evaluate the referral decision following orthopaedic care in PC+ and in particular to evaluate the influence of diagnostic tests on this decision. Therefore, retrospective monitoring data of patients visiting PC+ for orthopaedic care was used. Data was divided into two periods; P1 and P2. During P2, specialists in PC+ were able to request additional diagnostic tests (such as ultrasounds and MRIs). A total of 2,438 patients visiting PC+ for orthopaedic care were included in the analysis. The primary outcome was the referral decision following PC+ (back to the general practitioner (GP) or referral to outpatient hospital care). Independent variables were consultation- and patient-related predictors. To describe variations in the referral decision, logistic regression modelling was used. Results show that during P2, significantly more patients were referred back to their GP. Moreover, the multivariable analysis show a significant effect of patient age on the referral decision (OR 0.86, 95% CI = 0.81-0.91) and a significant interaction was found between the treating specialist and the period (p = 0.015) and between patient's diagnosis and the period (p ≤ 0.001). Despite the significant impact of the possibility of requesting additional diagnostic tests in PC+, it is important to discuss the extent to which the availability of diagnostic tests fits within the vision of PC+. In addition, selecting appropriate profiles for specialists and patients for PC+ are necessary to further optimise the effectiveness and cost of care.
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Affiliation(s)
- Esther H. A. van den Bogaart
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Marieke D. Spreeuwenberg
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Mariëlle E. A. L. Kroese
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Mark W. van den Boogaart
- Department of Orthopaedic Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Tim A. E. J. Boymans
- Department of Orthopaedic Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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van Hoof SJM, Quanjel TCC, Kroese MEAL, Spreeuwenberg MD, Ruwaard D. Substitution of outpatient hospital care with specialist care in the primary care setting: A systematic review on quality of care, health and costs. PLoS One 2019; 14:e0219957. [PMID: 31369567 PMCID: PMC6675042 DOI: 10.1371/journal.pone.0219957] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 07/03/2019] [Indexed: 01/17/2023] Open
Abstract
RATIONALE, AIMS AND OBJECTIVE Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting. METHOD The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible. RESULTS A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers. CONCLUSIONS Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design.
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Affiliation(s)
- Sofie J. M. van Hoof
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Tessa C. C. Quanjel
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Mariëlle E. A. L. Kroese
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Marieke D. Spreeuwenberg
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
- Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, the Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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Smeele P, Kroese MEAL, Spreeuwenberg MD, Ruwaard D. Substitution of hospital care with Primary Care Plus: differences in referral patterns according to specialty, specialist and diagnosis group. BMC FAMILY PRACTICE 2019; 20:81. [PMID: 31185921 PMCID: PMC6560871 DOI: 10.1186/s12875-019-0961-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 05/06/2019] [Indexed: 01/17/2023]
Abstract
Background Primary Care Plus (PC+) is an intervention where patients consult specialists in a primary care setting outside the hospital. Two facilities have been founded in the city of Maastricht, the Netherlands. Main aim is to achieve substitution of hospital care with primary care and hence reduce costs. The objective of this study is to evaluate referral patterns per specialty, specialist and diagnosis group, as input for deliberations to optimise substitution. Methods Prospectively collected referral data after PC+ consultations between November 2014 and March 2016 was analysed for eight participating specialties. Primary outcomes were differences in referral patterns per specialty, specialist and diagnosis group. Absolute counts and percentages were recorded for categorical variables, means and standard deviations for continuous variables. Statistical analyses were performed using IBM SPSS Statistics 23 (SPSS Inc., Chicago, IL). Results In total 4536 patients were seen in PC+; 3132 (69.0%) were referred back to the general practitioner (GP), whereas 1275 (28.1%) were referred to secondary care. Referral information of 130 (2.9%) patients was unknown. Large differences in referral numbers to secondary care after PC+ consultation were found between specialties (from 8.6% (gynaecology) to 43.8% (orthopaedic surgery)), specialists (14.5 to 65.2%) and diagnosis groups (11.1 to 93.4%). Conclusions Wide variation in referral numbers to secondary care between specialties, specialists and diagnosis groups exists after PC+ consultations. This data indicates that deliberation and further research is needed in order to optimize substitution initiatives like PC+.
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Affiliation(s)
- Paul Smeele
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, PO Box 616, 6200, MD, Maastricht, The Netherlands.
| | - Mariëlle E A L Kroese
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, PO Box 616, 6200, MD, Maastricht, The Netherlands
| | - Marieke D Spreeuwenberg
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, PO Box 616, 6200, MD, Maastricht, The Netherlands.,Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, PO Box 616, 6200, MD, Maastricht, The Netherlands
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Quanjel TCC, Struijs JN, Spreeuwenberg MD, Baan CA, Ruwaard D. Shifting hospital care to primary care: An evaluation of cardiology care in a primary care setting in the Netherlands. BMC FAMILY PRACTICE 2018; 19:55. [PMID: 29743021 PMCID: PMC5941471 DOI: 10.1186/s12875-018-0734-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 04/18/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital. METHODS This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus. RESULTS In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus. CONCLUSIONS To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus. TRIAL REGISTRATION NUMBER NTR6629 (Data registered: 25-08-2017) (registered retrospectively).
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Affiliation(s)
- Tessa C. C. Quanjel
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Jeroen N. Struijs
- Department for Quality of Care and Health Economics, Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Marieke D. Spreeuwenberg
- Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Caroline A. Baan
- Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, Tilburg, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Quanjel TCC, Winkens A, Spreeuwenberg MD, Struijs JN, Winkens RAG, Baan CA, Ruwaard D. Does an in-house internist at a GP practice result in reduced referrals to hospital-based specialist care? Scand J Prim Health Care 2018; 36:99-106. [PMID: 29376458 PMCID: PMC5901446 DOI: 10.1080/02813432.2018.1426147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 01/03/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention. DESIGN A retrospective interrupted times series study. SETTING Two multidisciplinary general practitioner (GP) practices. INTERVENTION An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings. SUBJECTS The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting. MAIN OUTCOME MEASURES The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period. RESULTS It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period. CONCLUSIONS This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting. Key Points An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.
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Affiliation(s)
- Tessa C. C. Quanjel
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Anne Winkens
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Marieke D. Spreeuwenberg
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Jeroen N. Struijs
- Department for Quality of Care and Health Economics, Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
- Department for Public Health and Primary Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ron A. G. Winkens
- Diagnostic Centre, Maastricht University Medical Centre (Maastricht UMC+), Maastricht, The Netherlands
| | - Caroline A. Baan
- Department for Quality of Care and Health Economics, Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
- Scientific Centre for Transformation in Care and Welfare (Tranzo), University of Tilburg, Tilburg, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Aller MB, Vargas I, Coderch J, Vázquez ML. Doctors' opinion on the contribution of coordination mechanisms to improving clinical coordination between primary and outpatient secondary care in the Catalan national health system. BMC Health Serv Res 2017; 17:842. [PMID: 29273045 PMCID: PMC5741878 DOI: 10.1186/s12913-017-2690-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 11/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical coordination is considered a health policy priority as its absence can lead to poor quality of care and inefficiency. A key challenge is to identify which strategies should be implemented to improve coordination. The aim is to analyse doctors' opinions on the contribution of mechanisms to improving clinical coordination between primary and outpatient secondary care and the factors influencing their use. METHODS A qualitative descriptive study in three healthcare networks of the Catalan national health system. A two-stage theoretical sample was designed: in the first stage, networks with different management models were selected; in the second, primary care (n = 26) and secondary care (n = 24) doctors. Data were collected using semi-structured interviews. Final sample size was reached by saturation. A thematic content analysis was conducted, segmented by network and care level. RESULTS With few differences across networks, doctors identified similar mechanisms contributing to clinical coordination: 1) shared EMR facilitating clinical information transfer and uptake; 2) mechanisms enabling problem-solving communication and agreement on clinical approaches, which varied across networks (joint clinical case conferences, which also promote mutual knowledge and training of primary care doctors; virtual consultations through EMR and email); and 3) referral protocols and use of the telephone facilitating access to secondary care after referrals. Doctors identified organizational (insufficient time, incompatible timetables, design of mechanisms) and professional factors (knowing each other, attitude towards collaboration, concerns over misdiagnosis) that influence the use of mechanisms. DISCUSSION Mechanisms that most contribute to clinical coordination are feedback mechanisms, that is those based on mutual adjustment, that allow doctors to exchange information and communicate. Their use might be enhanced by focusing on adequate working conditions, mechanism design and creating conditions that promote mutual knowledge and positive attitudes towards collaboration.
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Affiliation(s)
- Marta-Beatriz Aller
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
| | - Ingrid Vargas
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
| | - Jordi Coderch
- Grup de Recerca en Serveis Sanitaris i Resultats en Salut; Serveis de Salut Integrats Baix Empordà, Hospital, 17-19 Edif. Fleming, 17230 Palamós, Spain
| | - Maria-Luisa Vázquez
- Health Policy and Health Services Research Group; Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avinguda Tibidabo 21, 08022 Barcelona, Spain
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MacFarlane A, Harrison R, Murray E, Wallace P. A qualitative study of communication during joint teleconsultations at the primary-secondary care interface. J Telemed Telecare 2016; 12 Suppl 1:24-6. [PMID: 16884570 DOI: 10.1258/135763306777978425] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
It has been suggested that joint teleconsultations can improve communication at the primary-secondary care interface. We examined data from a qualitative analysis of social interactions in teleconsultations between specialists and general practitioners. The primary interaction was between specialists and patients. The general practitioners mostly adopted a ‘back seat role’, listening and observing, but not becoming actively involved. Teleconsultations create a number of interactional difficulties, which are likely to impede implementation and sustainability.
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Affiliation(s)
- Anne MacFarlane
- Department of General Practice, National University of Ireland, Galway, Republic of Ireland.
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MacFarlane A, Harrison R, Murray E, Berlin A, Wallace P. A qualitative study of the educational potential of joint teleconsultations at the primary-secondary care interface. J Telemed Telecare 2016; 12 Suppl 1:22-4. [PMID: 16884569 DOI: 10.1258/135763306777978399] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We conducted an evaluation of joint teleconsultations involving specialists, general practitioners (GPs) and their patients. Semistructured interviews (n= 39) and focus groups (2 groups with specialists; 6 groups with GPs) were used to collect data to explore participants’ views on the educational aspect of joint teleconsultations, and to seek examples of learning that had taken place. The results showed that the teleconsultation was a complex situation in which some learning took place for the generalists, but overall participants were disappointed. Three themes emerged that could enhance the educational potential in future: generalists’ reasons for referral as an influence on perceived learning; lack of clarity among clinicians regarding their role and conduct; and the presence of patients as an inhibitor in doctor-doctor interactions.
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Affiliation(s)
- Anne MacFarlane
- Department of General Practice, National University of Ireland, Galway, Republic of Ireland.
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Mair FS, Goldstein P, Shiels C, Roberts C, Angus R, O'Connor J, Haycox A, Capewell S. Recruitment difficulties in a home telecare trial. J Telemed Telecare 2016; 12 Suppl 1:26-8. [PMID: 16884571 DOI: 10.1258/135763306777978371] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We analysed the difficulties encountered in recruiting predominantly older patients, suffering from an acute exacerbation of a chronic illness, to a randomized controlled trial of home telecare. Of 653 patients approached for study participation, after full assessment, 80% (519) met the trial eligibility criteria. Of these, 104 (20%) consented to study participation and 415 (80%) refused. A logistic regression model was constructed to examine independent effects of patient factors on probability of trial participation. Only two independent variables were associated with decreased likelihood of consent: increasing age (1 year older: odds ratio [OR] = 0.96); and being on inhaled steroid medication (OR = 0.60). The most common reason for refusal to participate, accounting for almost one-third of respondents, was a stated preference for a face-to-face nurse visiting service rather than a telecare service. Perhaps home telecare services should continue to be targeted at the more stable chronically ill population and not at those suffering from acute illness.
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Affiliation(s)
- F S Mair
- University of Glasgow, Glasgow, UK.
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van Hoof SJM, Kroese MEAL, Spreeuwenberg MD, Elissen AMJ, Meerlo RJ, Hanraets MMH, Ruwaard D. Substitution of Hospital Care with Primary Care: Defining the Conditions of Primary Care Plus. Int J Integr Care 2016; 16:12. [PMID: 27616956 PMCID: PMC5015530 DOI: 10.5334/ijic.2446] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To analyse barriers and facilitators in substituting hospital care with primary care to define preconditions for successful implementation. METHODS A descriptive feasibility study was performed to collect information on the feasibility of substituting hospital care with primary care. General practitioners were able to refer patients, about whom they had doubts regarding diagnosis, treatment and/or the need to refer to hospital care, to medical specialists who performed low-complex consultations at general practitioner practices. Qualitative data were collected through interviews with general practitioners and medical specialists, focus groups and notes from meetings in the Netherlands between April 2013 and January 2014. Data were analysed using a conventional content analysis which resulted in categorised barriers, facilitators and policy adjustments, after which preconditions were formulated. RESULTS The most important preconditions were make arrangements on governmental level, arrange a collective integrated IT-system, determine the appropriate profile for medical specialists, design a referral protocol for eligible patients, arrange deliberation possibilities for general practitioners and medical specialists and formulate a diagnostic protocol. CONCLUSIONS The barriers, facilitators and formulated preconditions provided relevant input to change the design of substituting hospital care with primary care.
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Affiliation(s)
- Sofie Johanna Maria van Hoof
- Department of Health Services Research, Faculty of Health, Medicine and
Life Sciences, Maastricht University, Maastricht, The Netherlands
| | | | - Marieke Dingena Spreeuwenberg
- Department of Health Services Research, Faculty of Health, Medicine and
Life Sciences, Maastricht University, Maastricht, The Netherlands; Centre for
Technology in Care, Zuyd University of Applied Sciences, Heerlen, The
Netherlands
| | - Arianne Mathilda Josephus Elissen
- Department of Health Services Research, Faculty of Health, Medicine and
Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Ronald Johan Meerlo
- Primary Care Organisation Care in Development (ZIO), Maastricht, The
Netherlands
| | | | - Dirk Ruwaard
- Department of Health Services Research, Faculty of Health, Medicine and
Life Sciences, Maastricht University, Maastricht, The Netherlands
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Saillant S, Hudelson P, Dominicé Dao M, Junod Perron N. The primary care physician/psychiatrist joint consultation: A paradigm shift in caring for patients with mental health problems? PATIENT EDUCATION AND COUNSELING 2016; 99:279-283. [PMID: 26341942 DOI: 10.1016/j.pec.2015.08.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 08/21/2015] [Accepted: 08/22/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Thirty to forty percent of patients seen in primary care medicine suffer from mental health problems, but primary care physicians (PCPs) often feel unprepared to deal with their patients' mental health problems. Joint consultations conducted with a liaison psychiatrist can help. The purpose of this study was to evaluate the experience of joint consultations in a primary care service in Geneva, Switzerland. METHODS We retrospectively analyzed reports of psychiatric evaluations conducted between October 2010 and August 2012 (n=182), in the Primary Care Service of the Geneva University Hospitals. We also carried out 4 focus groups with 23 physicians-in-training to explore their experiences and perceptions of the joint consultations. RESULTS Seventy two percent of the evaluations resulted in a psychiatric diagnosis. Psychiatric follow-up was not considered necessary in 61% of cases. Focus groups revealed that prior to experiencing joint consultations, PCPs considered mental health problems to be the domain of psychiatrists and outside their own area of competence. Joint consultations helped to demystify the role of psychiatrists, reduce their anxiety and increase PCPs' confidence in dealing with patients' mental health problems. CONCLUSION Joint consultations enabled PCPs to shift away from a dichotomous view of somatic versus mental health problems and their management, and towards a more integrated view. IMPLICATIONS FOR PRACTICE Joint consultations provide a useful strategy for training primary care physicians in the management of mental health problems. Integrated management of somatic and mental health problems can lead to a better understanding of the patient and improve the therapeutic relationship.
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Affiliation(s)
- S Saillant
- Centre for Psychiatric Emergencies and Liaison Psychiatry, Neuchâtel Psychiatry Center (CNP), Maladière 45, CH-2000 Neuchâtel, Switzerland.
| | - P Hudelson
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 4, rue Gabrielle Perret-Gentil, CH-1211 Geneva 14, Switzerland.
| | - M Dominicé Dao
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 4, rue Gabrielle Perret-Gentil, CH-1211 Geneva 14, Switzerland.
| | - N Junod Perron
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, 4, rue Gabrielle Perret-Gentil, CH-1211 Geneva 14, Switzerland.
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Mallon D, Vernacchio L, Trudell E, Antonelli R, Nurko S, Leichtner AM, Lightdale JR. Shared care: a quality improvement initiative to optimize primary care management of constipation. Pediatrics 2015; 135:e1300-7. [PMID: 25896837 PMCID: PMC4411778 DOI: 10.1542/peds.2014-1962] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric constipation is commonly managed in the primary care setting, where there is much variability in management and specialty referral use. Shared Care is a collaborative quality improvement initiative between Boston Children's Hospital and the Pediatric Physician's Organization at Children's (PPOC), through which subspecialists provide primary care providers with education, decision-support tools, pre-referral management recommendations, and access to advice. We investigated whether Shared Care reduces referrals and improves adherence to established clinical guidelines. METHODS We reviewed the primary care management of patients 1 to 18 years old seen by a Boston Children's Hospital gastroenterologist and diagnosed with constipation who were referred from PPOC practices in the 6 months before and after implementation of Shared Care. Charts were assessed for patient factors and key components of management. We also tracked referral rates for all PPOC patients for 29 months before implementation and 19 months after implementation. RESULTS Fewer active patients in the sample were referred after implementation (61/27,365 [0.22%] vs 90/27,792 [0.36%], P = .003). The duration of pre-referral management increased, and the rate of fecal impaction decreased after implementation. No differences were observed in documentation of key management recommendations. Analysis of medical claims showed no statistically significant change in referrals. CONCLUSIONS A multifaceted initiative to support primary care management of constipation can alter clinical care, but changes in referral behavior and pre-referral management may be difficult to detect and sustain. Future efforts may benefit from novel approaches to provider engagement and systems integration.
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Affiliation(s)
- Daniel Mallon
- Divisions of Gastroenterology, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;
| | - Louis Vernacchio
- General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Pediatric Physicians’ Organization at Children’s, Brookline, Massachusetts; and
| | - Emily Trudell
- Pediatric Physicians’ Organization at Children’s, Brookline, Massachusetts; and
| | - Richard Antonelli
- General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Samuel Nurko
- Divisions of Gastroenterology, and ,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alan M. Leichtner
- Divisions of Gastroenterology, and ,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jenifer R. Lightdale
- Divisions of Gastroenterology, and ,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Division of Pediatric Gastroenterology, University of Massachusetts Memorial Children’s Medical Center, Worcester, Massachusetts
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Cravo Oliveira T, Barlow J, Bayer S. The association between general practitioner participation in joint teleconsultations and rates of referral: a discrete choice experiment. BMC FAMILY PRACTICE 2015; 16:50. [PMID: 25896515 PMCID: PMC4443603 DOI: 10.1186/s12875-015-0261-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 03/27/2015] [Indexed: 11/17/2022]
Abstract
Background Joint consultations – such as teleconsultations – provide opportunities for continuing education of general practitioners (GPs). It has been reported this form of interactive case-based learning may lead to fewer GP referrals, yet these studies have relied on expert opinion and simple frequencies, without accounting for other factors known to influence referrals. We use a survey-based discrete choice experiment of GPs’ referral preferences to estimate how referral rates are associated with participation in joint teleconsultations, explicitly controlling for a number of potentially confounding variables. Methods We distributed questionnaires at two meetings of the Portuguese Association of General Practice. GPs were presented with descriptions of patients with dermatological lesions and asked whether they would refer based on the waiting time, the distance to appointment, and pressure from patients for a referral. We analysed GPs’ responses to multiple combinations of these factors, coupled with information on GP and practice characteristics, using a binary logit model. We estimated the probabilities of referral of different lesions using marginal effects. Results Questionnaires were returned by 44 GPs, giving a total of 721 referral choices. The average referral rate for the 11 GPs (25%) who had participated in teleconsultations was 68.1% (range 53-88%), compared to 74.4% (range 47-100%) for the remaining physicians. Participation in teleconsultations was associated with reductions in the probabilities of referral of 17.6% for patients presenting with keratosis (p = 0.02), 42.3% for psoriasis (p < 0.001), 8.4% for melanoma (p = 0.14), and 5.4% for naevus (p = 0.19). Conclusions The results indicate that GP participation in teleconsultations is associated with overall reductions in referral rates and in variation across GPs, and that these effects are robust to the inclusion of other factors known to influence referrals. The reduction in range, coupled with different effects for different clinical presentations, may suggest an educational effect. However, more research is needed to establish whether there are causal relationships between participation in teleconsultations, continuing education, and referral rates.
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Affiliation(s)
- Tiago Cravo Oliveira
- Research Associate, Imperial College Business School, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK.
| | - James Barlow
- Chair in Technology and Innovation Management, Imperial College Business School, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK.
| | - Steffen Bayer
- Assistant Professor, Program in Health Services & Systems Research, Duke-NUS Graduate Medical School, 8 College Road, Singapore, 169857, Singapore.
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Atkinson R, Chamley M, Kariyawasam D, Forbes A. Collaborative diabetes virtual clinics – a service evaluation and clinical audit. ACTA ACUST UNITED AC 2015. [DOI: 10.1179/2057331615z.0000000004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Burn D, May S, Edwards L. General Practitioners' Views About an Orthopaedic Clinical Assessment Service. PHYSIOTHERAPY RESEARCH INTERNATIONAL 2014; 19:176-85. [DOI: 10.1002/pri.1581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 12/03/2013] [Accepted: 02/13/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Damon Burn
- Trauma Orthopaedic and Musculoskeletal Services; Walsall Healthcare NHS Trust; Walsall UK
| | - Stephen May
- Faculty of Health and Wellbeing; Sheffield Hallam University; Sheffield UK
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Roberts LJ, Lamont EG, Lim I, Sabesan S, Barrett C. Telerheumatology: an idea whose time has come. Intern Med J 2013; 42:1072-8. [PMID: 22931307 DOI: 10.1111/j.1445-5994.2012.02931.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Australia is a vast country with one-third of the population living outside capital cities. Providing specialist rheumatologist services to regional, rural and remote Australians has generally required expensive and time-consuming travel for the patient and/or specialist. As a result, access to specialist care for remote Australians is poor. Rheumatoid arthritis is a common disease, but like many rheumatic diseases, it is complex to treat. Time-dependent joint damage and disability occur unless best evidence care is implemented. The relatively poor access to rheumatologist care allotted to nonmetropolitan Australians therefore represents a significant cause of potentially preventable disability in Australia. Telehealth has the potential to improve access to specialist rheumatologists for patients with rheumatoid arthritis and other rheumatic diseases, thereby decreasing the burden of disability caused by these diseases. Advances in videoconferencing technology, the national broadband rollout and recent Federal government financial incentives have led to a heightened interest in exploring the use of this technology in Australian rheumatology practice. This review summarises the current evidence base, outlines telehealth's strengths and weaknesses in managing rheumatic disease, and discusses the technological, medicolegal and financial aspects of this model of care. A mixed model offering both face-to-face and virtual consultations appears to be the best option, as it can overcome the barriers to accessing care posed by distance while also mitigating the risks of virtual consultation.
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Affiliation(s)
- L J Roberts
- School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
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Buchbinder R, Staples MP, Shanahan EM, Roos JF. General practitioner management of shoulder pain in comparison with rheumatologist expectation of care and best evidence: an Australian national survey. PLoS One 2013; 8:e61243. [PMID: 23613818 PMCID: PMC3628939 DOI: 10.1371/journal.pone.0061243] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 03/07/2013] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To determine whether current care for common shoulder problems in Australian general practice is in keeping with rheumatologist expectations and the best available evidence. METHODS We performed a mailed survey of a random sample of 3500 Australian GPs and an online survey of all 270 rheumatologists in Australia in June 2009. Each survey included four vignettes (first presentation of shoulder pain due to rotator cuff tendinopathy, acute rotator cuff tear in a 45 year-old labourer and early and later presentation of adhesive capsulitis). For each vignette, GPs were asked to indicate their management, rheumatologists were asked to indicate appropriate primary care, and we determined best available evidence from relevant Cochrane and other systematic reviews and published guidelines. RESULTS Data were available for at least one vignette for 614/3500 (17.5%) GPs and 64 (23.8%) rheumatologists. For first presentation of rotator cuff tendinopathy, 69% and 82% of GPs and 50% and 56% rheumatologists would order a shoulder X-ray and ultrasound respectively (between group comparisons P = 0.004 and P<0001). Only 66% GPs and 60% rheumatologists would refer to an orthopaedic surgeon for the acute rotator cuff tear. For adhesive capsulitis, significantly more rheumatologists recommended treatments of known benefit (e.g. glucocorticoid injection (56% versus 14%, P<0.0001), short course of oral glucocorticoids (36% versus 6%, p<0.0001) and arthrographic distension of the glenohumeral joint (41% versus 19%, P<0.0001). CONCLUSIONS There is a mismatch between the stated management of common shoulder problems encountered in primary care by GPs, rheumatologist expectations of GP care and the available evidence.
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Affiliation(s)
- Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Health, Monash University, Melbourne, Victoria, Australia.
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Do first opinions affect second opinions? J Gen Intern Med 2012; 27:1265-71. [PMID: 22539066 PMCID: PMC3445697 DOI: 10.1007/s11606-012-2056-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 01/11/2012] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians. OBJECTIVE To evaluate whether physicians' judgment is affected by another medical opinion given to a patient. DESIGN Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician's opinion was (study group), and the other group was not told what it was (control group). PARTICIPANTS A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population). MEASUREMENTS Scoring was by choice of less or more interventional treatment in the scenarios. We used χ(2) tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician's responses. RESULTS Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) =4.6, p=0.03; OR=1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p=0.039; scenario 2, p<0.001; scenario 3, p=0.033; scenario 6, p<0.001). These effects were insignificant among the neurologists [F (1,158) =0.44, p=0.51; OR=1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) =0.752, p=0.473; neurologists: F (2,154) =1.951, p=0.146]. CONCLUSIONS The exploratory survey showed that in some cases physicians' judgments may be affected by other physicians' opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.
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Abstract
CONTEXT In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines. METHODS This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care. FINDINGS PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management). CONCLUSIONS There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.
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Affiliation(s)
- Ateev Mehrotra
- University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA 15213, USA.
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García Olmos L, Gervas J. [Organisational reforms in the relationships between general doctors and specialists: impact on referrals]. Aten Primaria 2009; 42:52-6. [PMID: 19446926 DOI: 10.1016/j.aprim.2009.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 02/18/2009] [Indexed: 10/20/2022] Open
Affiliation(s)
- Luís García Olmos
- Unidad de Docencia e Investigación, Gerencia de Atención Primaria, Madrid, Equipo CESCA, Cátedra U.A.M.-Novartis de Medicina de Familia, Madrid, Spain.
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Scalvini S, Tridico C, Glisenti F, Giordano A, Pirini S, Peduzzi P, Auxilia F. The SUMMA Project: A Feasibility Study on Telemedicine in Selected Italian Areas. Telemed J E Health 2009; 15:261-9. [DOI: 10.1089/tmj.2008.0109] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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McKenna C, Bojke L, Manca A, Adebajo A, Dickson J, Helliwell P, Morton V, Russell I, Torgerson D, Watson J. Shoulder acute pain in primary health care: is retraining GPs effective? The SAPPHIRE randomized trial: a cost-effectiveness analysis. Rheumatology (Oxford) 2009; 48:558-63. [PMID: 19258378 DOI: 10.1093/rheumatology/kep008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To assess the cost-effectiveness of providing practical training to general practitioners (GPs) in shoulder problems, and administering a local anaesthetic (lignocaine) vs steroidal (cortisone) injection. METHODS A cost-effectiveness analysis conducted alongside a cluster randomized trial with a factorial design, in general practices across five centres within the UK. A total of 155 participant GPs were randomized to receive training or no training with 200 participants randomized to either lignocaine or cortisone. Health care costs, quality-adjusted life years (QALYs) and incremental cost per QALY gained over 1 year estimated from a health system and a societal perspective were the main outcomes measured. RESULTS Over 1 year, training GPs costs on average an additional pound sterling 211 (95% credibility interval - pound sterling 237, pound sterling 661) than no training and produces higher mean QALYs (0.075; -0.004, 0.154) per patient, yielding an incremental cost-effectiveness ratio of pound sterling 2813 per QALY gained for trained GPs. Over the same period of 1 year, lignocaine costs an average of pound sterling 122 more (- pound sterling 232, pound sterling 476) than cortisone and produces virtually no differential gain in mean QALYs (0.001; -0.068, 0.070), yielding an incremental cost per QALY gained of pound sterling 122,000 for lignocaine compared with cortisone. Across a range of cost-effectiveness thresholds, cortisone is as cost effective to inject as lignocaine. The probability that training is cost effective is above 0.95 at thresholds above pound sterling 20,000. CONCLUSIONS Providing practical training to GPs about shoulder problems is cost effective and there is little uncertainty regarding this decision. The choice between lignocaine and cortisone is more uncertain and it is likely that there is significant value of further research to reduce this uncertainty. TRIAL REGISTRATION The International Standard Randomised Controlled Trial Number is 58 537 244.
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Affiliation(s)
- Claire McKenna
- Centre for Health Economics, University of York, York, UK.
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Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, Pritchard C, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2008; 2008:CD005471. [PMID: 18843691 PMCID: PMC4164370 DOI: 10.1002/14651858.cd005471.pub2] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved. OBJECTIVES To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness. SEARCH STRATEGY We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. Updated searches were conducted in MEDLINE and the EPOC specialised register up to October 2007. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes. DATA COLLECTION AND ANALYSIS A minimum of two reviewers independently extracted data and assessed study quality. MAIN RESULTS Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Four studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices, a new slot system for referrals and requiring a second 'in-house' opinion prior to referral), all of which were effective. Four studies (five comparisons) evaluated financial interventions. One study evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates. AUTHORS' CONCLUSIONS There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
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Affiliation(s)
- Ayub Akbari
- Department of Medicine/Division of Nephrology, Kidney Research Center/University of Ottawa, Ottawa Hospital, Riverside Hospitall, 1967 Rverside Drive, Suite 5-25, Ottawa, Ontario, Canada, K1H 7W9.
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Berendsen AJ, Benneker WHGM, Meyboom-de Jong B, Klazinga NS, Schuling J. Motives and preferences of general practitioners for new collaboration models with medical specialists: a qualitative study. BMC Health Serv Res 2007; 7:4. [PMID: 17207278 PMCID: PMC1774564 DOI: 10.1186/1472-6963-7-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 01/05/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Collaboration between general practitioners (GPs) and specialists has been the focus of many collaborative care projects during the past decade. Unfortunately, quite a number of these projects failed. This raises the question of what motivates GPs to initiate and continue participating with medical specialists in new collaborative care models. The following two questions are addressed in this study: What motivates GPs to initiate and sustain new models for collaborating with medical specialists? What kind of new collaboration models do GPs suggest? METHODS A qualitative study design was used. Starting in 2003 and finishing in 2005, we conducted semi-structured interviews with a purposive sample of 21 Dutch GPs. The sampling criteria were age, gender, type of practice, and practice site. The interviews were recorded, fully transcribed, and analysed by two researchers working independently. The resulting motivational factors and preferences were grouped into categories. RESULTS 'Developing personal relationships' and 'gaining mutual respect' appeared to dominate when the motivational factors were considered. Besides developing personal relationships with specialists, the GPs were also interested in familiarizing specialists with the competencies attached to the profession of family medicine. Additionally, they were eager to increase their medical knowledge to the benefit of their patients. The GPs stated a variety of preferences with respect to the design of new models of collaboration. CONCLUSION Developing personal relationships with specialists appeared to be one of the dominant motives for increased collaboration. Once the relationships have been formed, an informal network with occasional professional contact seemed sufficient. Although GPs are interested in increasing their knowledge, once they have reached a certain level of expertise, they shift their focus to another specialty. The preferences for new collaboration models are diverse. A possible explanation for the differences in the preferences is that professionals are more knowledge driven than organisation driven as the acquiring of new knowledge is considered more important than the route by which this is achieved. A new collaboration model seems a way to acquire knowledge. Once this is achieved the importance of a model possibly diminishes, whereas the professional relationships last.
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Affiliation(s)
- Annette J Berendsen
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Wim HGM Benneker
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Betty Meyboom-de Jong
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - Niek S Klazinga
- Department of Social Medicine, Academic Medical Centre, University of Amsterdam, The Netherlands
| | - Jan Schuling
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
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Páe Borda A, Redondo González E, Río González E, Linares Quevedo A, Sáenz Medina J, Castillón Vela I. Adecuación de las derivaciones desde Atención Primaria a un Servicio de Urología. Actas Urol Esp 2007; 31:1166-71. [DOI: 10.1016/s0210-4806(07)73780-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schellings R, Kessels AG, ter Riet G, Knottnerus JA, Sturmans F. Randomized consent designs in randomized controlled trials: Systematic literature search. Contemp Clin Trials 2006; 27:320-32. [PMID: 16388991 DOI: 10.1016/j.cct.2005.11.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2004] [Revised: 09/14/2005] [Accepted: 11/22/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND Three types of randomized consent designs are distinguished and ranked according to the extent to which participants are informed about treatment options: single-consent (those in the experimental group learn about their assigned treatment), incomplete-double-consent (all participants learn about their assigned treatment), and complete-double-consent (all participants learn about all treatments studied). All are methodologically, ethically, and judicially controversial. Even so, their use is justified if blinding is deemed necessary, but impossible to achieve by sham procedures (placebo), and experimental treatment seems attractive to potential participants. OBJECTIVE The aim of this study is to give a comprehensive overview of the use of randomized consent designs. Data sources are MEDLINE (1/1977-2/2003), EMBASE (1/1984-2/2003), PsycINFO (1/1996-2/2003), the Cochrane Library, and the Science Citation Index database. REVIEW METHODS Eligible were studies using a randomized consent design. Cluster randomized trials were excluded. One reviewer selected and data-extracted eligible papers. A second reviewer independently data-extracted 10% of the papers. Data on country of study conduct, year of commencement, area of medicine, type of design, reason(s) for use, details on approval by a research ethics committee, the index and reference intervention, nature of endpoints, and details on collection of data were extracted. Furthermore, for each trial, the rates of non-compliance and loss to follow-up were registered by treatment arm. The three types of randomized consent designs were compared as to differences between the rates of non-compliance and loss to follow-up in the separate trial arms. RESULTS Randomized consent designs are seldom used (n=50). When used, they have often been used in the wrong circumstances (misuse). In 65% of the studies the non-compliance in the index group is larger than in the reference group. Contrary to expectation, trials using the incomplete-double design were associated with significantly higher rates of non-compliance and loss to follow-up in the reference groups than trials employing the other two versions. CONCLUSION Trialists and physicians should be aware of the proper indication for the use of randomized consent designs.
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Affiliation(s)
- Ron Schellings
- Public Health Supervisory Service of the Netherlands, the Health Care Inspectorate, The Hague, P.O. Box 90137 5200 MA Den Bosch, The Netherlands.
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Grimshaw JM, Winkens RAG, Shirran L, Cunningham C, Mayhew A, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev 2005:CD005471. [PMID: 16034981 DOI: 10.1002/14651858.cd005471] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The primary care specialist interface is a key organisational feature of many health care systems. Patients are referred to specialist care when investigation or therapeutic options are exhausted in primary care and more specialised care is needed. Referral has considerable implications for patients, the health care system and health care costs. There is considerable evidence that the referral processes can be improved. OBJECTIVES To estimate the effectiveness and efficiency of interventions to change outpatient referral rates or improve outpatient referral appropriateness. SEARCH STRATEGY We conducted electronic searches of the Cochrane Effective Practice and Organisation of Care (EPOC) group specialised register (developed through extensive searches of MEDLINE, EMBASE, Healthstar and the Cochrane Library) (February 2002) and the National Research Register. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series of interventions to change or improve outpatient referrals. Participants were primary care physicians. The outcomes were objectively measured provider performance or health outcomes. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data and assessed study quality. MAIN RESULTS Seventeen studies involving 23 separate comparisons were included. Nine studies (14 comparisons) evaluated professional educational interventions. Ineffective strategies included: passive dissemination of local referral guidelines (two studies), feedback of referral rates (one study) and discussion with an independent medical adviser (one study). Generally effective strategies included dissemination of guidelines with structured referral sheets (four out of five studies) and involvement of consultants in educational activities (two out of three studies). Three studies evaluated organisational interventions (patient management by family physicians compared to general internists, attachment of a physiotherapist to general practices and requiring a second 'in-house' opinion prior to referral), all of which were effective. Five studies (six comparisons) evaluated financial interventions. Two studies evaluating change from a capitation based to mixed capitation and fee-for-service system and from a fee-for-service to a capitation based system (with an element of risk sharing for secondary care services) observed a reduction in referral rates. Modest reductions in referral rates of uncertain significance were observed following the introduction of the general practice fundholding scheme in the United Kingdom (UK). One study evaluating the effect of providing access to private specialists demonstrated an increase in the proportion of patients referred to specialist services but no overall effect on referral rates. AUTHORS' CONCLUSIONS There are a limited number of rigorous evaluations to base policy on. Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence. The effects of 'in-house' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising.
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Affiliation(s)
- J M Grimshaw
- Ottawa Health Research Institute, 1053 Carling Avenue, Administration Building, Room 2-017, Ottawa, Ontario, Canada, AB25 2ZD.
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Schols JM, de Veer AJ. Information Exchange Between General Practitioner and Nursing Home Physician in the Netherlands. J Am Med Dir Assoc 2005; 6:219-25. [DOI: 10.1016/j.jamda.2005.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Luis Zambrana García J. Consultas ambulatorias de atención especializada. Presente y propuestas de futuro. Med Clin (Barc) 2004. [DOI: 10.1016/s0025-7753(04)74481-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Althabe F, Belizán JM, Villar J, Alexander S, Bergel E, Ramos S, Romero M, Donner A, Lindmark G, Langer A, Farnot U, Cecatti JG, Carroli G, Kestler E. Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial. Lancet 2004; 363:1934-40. [PMID: 15194252 DOI: 10.1016/s0140-6736(04)16406-4] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Latin America has a high rate of caesarean sections. We tested the hypothesis that a hospital policy of mandatory second opinion, based on the best existing scientific evidence, reduces the hospital caesarean section rate by 25%, without increasing maternal and perinatal morbidity and mortality. METHODS 36 hospitals in Argentina (18), Brazil (eight), Cuba (four), Guatemala (two), and Mexico (four), were randomly assigned to intervention or control in a matched pair design. All physicians in the intervention hospitals deciding a non-emergency caesarean section had to follow a policy of mandatory second opinion. The primary outcome was the overall caesarean section rate in the hospitals after a 6-month implementation period. We also assessed women's satisfaction with labour and delivery care and physicians'acceptance of the second opinion policy. FINDINGS A total of 34 hospitals attending 149?276 deliveries were randomised and completed the protocol. The mandatory second opinion policy was associated with a small but significant reduction in rates of caesarean section (relative rate reduction 7.3%; 95% CI 0.2-14.5), mostly in intrapartum sections (12.6%; 0.6-24.7). Other maternal and neonatal outcomes and women's perceptions and satisfaction with the process of care were similarly distributed between the groups. INTERPRETATION In hospitals applying this policy of second opinion, 22 intrapartum caesarean sections could be prevented per 1000 deliveries, without affecting maternal or perinatal morbidity, and without affecting mothers' satisfaction with the care process.
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Affiliation(s)
- Fernando Althabe
- Latin American Center for Perinatology, Pan American Health Organization, WHO, Montevideo, Uruguay.
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Gruen RL, Weeramanthri TS, Knight SS, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database Syst Rev 2004; 2003:CD003798. [PMID: 14974038 PMCID: PMC9016793 DOI: 10.1002/14651858.cd003798.pub2] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Specialist medical practitioners have conducted clinics in primary care and rural hospital settings for a variety of reasons in many different countries. Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services. OBJECTIVES To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access, quality, health outcomes, patient satisfaction, use of services, and costs. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register (March 2002), the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 1, 2002), MEDLINE (including HealthStar) (1966 to May 2002), EMBASE (1988 to March 2002), CINAHL (1982 to March 2002), the Primary-Secondary Care Database previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester, a collection of studies from the UK collated in "Specialist Outreach Clinics in General Practice" (Roland 1998), and the reference lists of all retrieved articles. SELECTION CRITERIA Randomised trials, controlled before and after studies and interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings, either providing simple consultations or as part of complex multifaceted interventions. The participants were patients, specialists, and primary care providers. The outcomes included objective measures of access, quality, health outcomes, satisfaction, service use, and cost. DATA COLLECTION AND ANALYSIS Four reviewers working in pairs independently extracted data and assessed study quality. MAIN RESULTS 73 outreach interventions were identified covering many specialties, countries and settings. Nine studies met the inclusion criteria. Most comparative studies came from urban non-disadvantaged populations in developed countries. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes. REVIEWER'S CONCLUSIONS This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.
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Affiliation(s)
- Russell L Gruen
- University of MelbourneDepartment of SurgeryRoyal Melbourne HospitalParkville, Victoria 3050MelbourneAustralia
| | - Tarun S. Weeramanthri
- Department of Health in Western AustraliaPublic Health DivisionLevel 3, B Block189 Royal StreetEast PerthWestern AustraliaAustraliaWA 6004
| | - Stephen S.E. Knight
- Nelson R Mandela School of Medicine, University of Natal, Durban.Department of Community Health, School of Family and Public Health MedicinePrivate Bag 7CongellaSouth Africa4013
| | - Ross S Bailie
- Menzies School of Health Research and Flinders University NT Clinical SchoolPopulation Health and Chronic Diseases DivisionP.O.Box 41096CasuarinaNorthern TerritoryAustralia0811
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Makkar RPS, Monga A, Arora A, Mukhopadhyay S, Gupta AK. Self-referral to specialists--a dodgy proposition. INTERNATIONAL JOURNAL OF HEALTH CARE QUALITY ASSURANCE INCORPORATING LEADERSHIP IN HEALTH SERVICES 2003; 16:87-9. [PMID: 12870247 DOI: 10.1108/09526860310465591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients are often ill-equipped to know which speciality to choose for their health problem. Especially in the presence of non-specific symptoms, choosing the right specialist might not be so obvious. In such cases, misdirected self-referrals by patients to self-chosen specialists can sometimes lead to misdiagnosis resulting in unwarranted delays in getting the right treatment. The general physicians, on the other hand, are in a unique position to oversee the big picture of patients' health, and are therefore better equipped to identify and sort out their individual health problems. Hence instead of a specialist if the first place of contact for patients is a general physician, they are likely to be guided along the right path of treatment for their various health problems. Such a system will minimize errors on the part of the patients by making certain that they are referred to the appropriate specialists.
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Affiliation(s)
- Ravinder P S Makkar
- Department of Internal Medicine, Sitaram Bhartia Institute of Science and Research, New Delhi, India
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Jacklin PB, Roberts JA, Wallace P, Haines A, Harrison R, Barber JA, Thompson SG, Lewis L, Currell R, Parker S, Wainwright P. Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion. BMJ 2003; 327:84. [PMID: 12855528 PMCID: PMC164917 DOI: 10.1136/bmj.327.7406.84] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- P B Jacklin
- Department of Public Health Policy, London School of Hygiene and Tropical Medicine, London WC1 7HT.
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Schulpen GJ, Vierhout WP, van der Heijde DM, Landewé RB, Winkens RA, Wesselingh-Megens AM, van der Linden S. Patients at the outpatient rheumatology clinic: do they really need to be there? Eur J Intern Med 2003; 14:158-161. [PMID: 12798213 DOI: 10.1016/s0953-6205(03)00031-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND: The workload at many outpatient clinics within the Dutch health care system has been growing relentlessly, resulting in unacceptable waiting lists and reduced accessibility. Assessing streams of patients and introducing a method of accelerated referral of patients back to the general practitioner (GP) under specialist guidance could help to alleviate these problems. METHODS: Seventeen GPs collaborated with rheumatologists during a 2-year period in a 'joint consultation' model in which GPs and rheumatologists discussed patients together. All patient charts belonging to patients who had been referred to the outpatient clinic by these 17 GPs were identified. Rheumatologists assessed whether or not these patients could be referred back to the participating GPs under the guidance of the specialist in the joint consultation model. RESULTS: Of 276 eligible patients, 121 were discharged from the outpatient clinic. Eighty-seven patients required specialist follow-up, 22 patients refused to participate, and six patients were not entered into the study by the rheumatologist. Some 21 patients eventually entered the study, 18 of whom were referred back to the GP. CONCLUSION: The role of joint consultation appears to be limited. Improving the referral behavior of GPs should take precedence over transferring follow-up from the outpatient clinic to the primary care level.
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Affiliation(s)
- G J.C. Schulpen
- Department of Transmural Care, University Hospital Maastricht, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
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Schulpen GJC, Vierhout WPM, van der Heijde DM, Landewé RB, Winkens RAG, van der Linden S. Joint consultation of general practitioner and rheumatologist: does it matter? Ann Rheum Dis 2003; 62:159-61. [PMID: 12525386 PMCID: PMC1754440 DOI: 10.1136/ard.62.2.159] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the effects of joint consultation on referral behaviour of general practitioners (GPs) in a prospective cohort study. METHODS All patients with rheumatological complaints that 17 participating GPs, from the area of the University Hospital Maastricht, wanted to refer during a two year inclusion period (n=166) were eligible for inclusion. These patients were either referred to the outpatient clinic, or presented at a joint consultation held every six weeks at the practice of the GP, where groups of three GPs presented their patients to a visiting, consulting rheumatologist. The number of patients referred by each GP a year at the end of the trial, comparing participating and non-participating GPs, was the main outcome measure. RESULTS During two years of inclusion, the 17 participating GPs presented 166 patients. The number of patients referred by each GP a year decreased for the participating GPs by 62% at the end of the whole study. By contrast, non-participating GPs maintained the same rate of referral. The range of diagnoses remained proportionally the same throughout the study, with the exception of fibromyalgia. The referral rate of this diagnosis decreased significantly (p=0.001). CONCLUSIONS Joint consultation seems to be a good strategy in influencing the referral behaviour of GPs in the area of rheumatology. The decrease in referral is substantial and can subsequently lead to a reduction of waiting lists.
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Affiliation(s)
- G J C Schulpen
- Department of Transmural Care, University Hospital Maastricht, Maastricht, The Netherlands.
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Wallace PG, Haines A, Harrison R, Barber J, Thompson S, Jacklin P, Roberts J, Lewis L, Wainwright P. Design and performance of a multicentre, randomized controlled trial of teleconsulting. J Telemed Telecare 2002; 8 Suppl 2:94-5. [PMID: 12217154 DOI: 10.1177/1357633x020080s243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- P G Wallace
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK.
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Joint teleconsultations improve satisfaction among people referred for a specialist opinion. ACTA ACUST UNITED AC 2002. [DOI: 10.1054/ebhc.2002.0556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Baruffaldi F, Gualdrini G, Toni A. Comparison of asynchronous and realtime teleconsulting for orthopaedic second opinions. J Telemed Telecare 2002; 8:297-301. [PMID: 12396859 DOI: 10.1177/1357633x0200800509] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We studied a teleconsulting service for second opinions in orthopaedics. Three units of the national insurance organization for accidents at work were connected to a large orthopaedic hospital in Bologna. During a 20-month study, 65 consultations were provided: 51 (78%) by asynchronous (store-and-forward) consulting and 14 (22%) by realtime videoconferencing. All the consultations made use of radiology images (radiographs, computerized tomography scans, magnetic resonance imaging scans and ultrasound scans). Video-messages and still images were commonly used to support the asynchronous consultations. More data were transmitted on average for an asynchronous teleconsultation (8 MByte) than in a videoconference (5 MByte). The average time spent by orthopaedic specialists was slightly longer in videoconferences (21 min, SD 8) than in asynchronous teleconsultations (19 min, SD 8). The clinicians confidence in their diagnosis was generally good but was lower in asynchronous consultations. The main problem affecting the telemedicine service was the lack or the low quality of the information received from the referring sites. The clinical complexity of the case and the organizational requirements were declared to be the main factors affecting the choice of consulting procedure. The study showed that the asynchronous method was preferred in the majority of cases and could be easily integrated into clinical practice, although there were some concerns about the diagnostic quality of the information transmitted.
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Affiliation(s)
- F Baruffaldi
- Laboratorio di Tecnologia Medica, Istituti Ortopedici Rizzoli, Bologna, Italy.
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Abstract
General practitioners (GPs) deliver the majority of palliative care to patients in the last year of life. This article seeks to examine the nature of GP care, perceptions of the GPs themselves and others of that care, the adequacy of palliative care training, issues relating to accessibility of GPs to palliative care patients, and strategies that may be of use in encouraging more effective delivery of palliative care by GPs. Medline and PubMed databases from 1966 to 2000 were searched, and 135 references identified. Sixty-six of these described studies relevant to GP palliative care. GPs value this part of their work. Most of the time, patients appreciate the contribution the GP makes to palliative care particularly if the GP is accessible, takes time to listen, allows patient and carer to ventilate their feelings, and is seen to be making efforts made regarding symptom relief. However, reports from bereaved relatives suggest that palliative care is performed less well in the community than in other settings. GPs express discomfort about their competence to perform palliative care adequately. They tend to miss symptoms which are not treatable by them, or which are less common. However, with appropriate specialist support and facilities, GPs have been shown to deliver sound and effective care. GP comfort working with specialist teams increases with exposure to this form of patient management, as does the understanding of the potential other team members have in contributing to the care of the patient. Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes, patient satisfaction, improve effective use of resources and improve effective physician behaviour in other areas of medicine. Efforts by specialist services to develop formal involvement of GPs in the care of individual patients, may be an effective method of improving GP palliative care skills and appreciation of the roles specialist services can play.
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Affiliation(s)
- Geoffrey K Mitchell
- Centre for General Practice, University of Queensland Medical School, Herston Road, Herston 4006, Queensland, Australia.
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Amadio PC, Gabriel SE, Yawn BP, Harmsen WS, Ilstrup DM, Hill J. Short-term outcomes of acute knee injuries: does the provider make a difference? ARTHRITIS AND RHEUMATISM 2002; 47:361-5. [PMID: 12209480 DOI: 10.1002/art.10537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To compare the short-term outcomes of acute knee injuries treated by specialists and generalists. METHODS Using patient logs, 168 adults with acute knee injuries were identified; 131 (78%) completed a questionnaire 3 months after initial presentation. RESULTS The mean age of the 77 male and 54 female responders was 34.6 years (range 18-73 years). The injuries were classified as mild (n = 35), moderate (n = 75), or severe (n = 21). Most responders were satisfied with their care and outcome, but 22% noted some functional limitations. The 59 patients seeing an orthopedist were more likely to have had a severe injury, more physician visits, activity limitations, lost time from work or recreation, and more pain when compared with the 72 patients who never saw an orthopedist. Excluding surgical patients, however, satisfaction was not significantly different by provider. After multivariate modeling (adjusting for age, sex, injury severity, and diagnosis), there was no significant association between having seen an orthopedist and either treatment success or satisfaction. CONCLUSION With the exception of time lost for recuperation in our community there is little difference in short-term outcome for patients with acute knee injury not undergoing surgery, regardless of the specialty of the treating physician.
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Affiliation(s)
- Peter C Amadio
- Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
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Wallace P, Haines A, Harrison R, Barber J, Thompson S, Jacklin P, Roberts J, Lewis L, Wainwright P. Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial. Lancet 2002; 359:1961-8. [PMID: 12076550 DOI: 10.1016/s0140-6736(02)08828-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- P Wallace
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK.
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Wallace P, Haines A, Harrison R, Barber JA, Thompson S, Roberts J, Jacklin PB, Lewis L, Wainwright P. Design and performance of a multi-centre randomised controlled trial and economic evaluation of joint tele-consultations [ISRCTN54264250]. BMC FAMILY PRACTICE 2002; 3:1. [PMID: 11835692 PMCID: PMC65515 DOI: 10.1186/1471-2296-3-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2001] [Accepted: 01/11/2002] [Indexed: 12/02/2022]
Abstract
BACKGROUND Appropriate information flow is crucial to the care of patients, particularly at the interface between primary and secondary care. Communication problems can result from inadequate organisation and training, There is a major expectation that information and communication technologies may offer solutions, but little reliable evidence. This paper reports the design and performance of a multi-centre randomised controlled trial (RCT), unparalleled in telemedicine research in either scale or range of outcomes. The study investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing to perform joint tele-consultations as an alternative to general practitioner referral to the hospital specialist in the outpatient clinic. METHODS Joint tele-consultation services were established in both the Royal Free Hampstead NHS Trust in inner London, and the Royal Shrewsbury Hospitals Trust, in Shropshire. All the patients who gave consent to participate were randomised either to joint tele-consultation or to a routine outpatients appointment. The principal outcome measures included the frequency of decision by the specialist to offer a follow-up outpatient appointment, patient satisfaction (Ware Specific Questionnaire), wellbeing (SF12) and enablement (PEI), numbers of tests, investigations, procedures and treatments. RESULTS A total of 134 general practitioners operating from 29 practices participated in the trial, referring a total of 3170 patients to 20 specialists in ENT medicine, general medicine (including endocrinology, and rheumatology), gastroenterology, orthopaedics, neurology and urology. Of these, 2094 patients consented to participate in the study and were correctly randomised. There was a 91% response rate to the initial assessment questionnaires, and analysis showed equivalence for all key characteristics between the treatment and control groups. CONCLUSION We have designed and performed a major multi-centre trial of teleconsultations in two contrasting centres. Many problems were overcome to enable the trial to be carried out, with a considerable development and learning phase. A lengthier development phase might have enabled us to improve the patient selection criteria, but there is a window of opportunity for these developments, and we believe that our approach was appropriate, allowing the evaluation of the technology before its widespread implementation.
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Affiliation(s)
- Paul Wallace
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, Rowland Hill Street, London NW3 2PF, UK
| | - Andrew Haines
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1, UK
| | - Robert Harrison
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, Rowland Hill Street, London NW3 2PF, UK
| | - Julie A Barber
- Department of Primary Care and Population Sciences, Royal Free and University College Medical School, Rowland Hill Street, London NW3 2PF, UK
- University College Hospitals Research and Development Directorate, Hampstead Road, London NW1 UK
| | | | | | - Paul B Jacklin
- London School of Hygiene and Tropical Medicine, Keppel Street, London WC1, UK
| | - Leo Lewis
- Centre for Health Informatics, School of Health Science, University of Wales, Swansea, UK
| | - Paul Wainwright
- Centre for Health Informatics, School of Health Science, University of Wales, Swansea, UK
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Atcheson SG, Brunner RL, Greenwald EJ, Rivera VG, Cox JC, Bigos SJ. Paying doctors more: use of musculoskeletal specialists and increased physician pay to decrease workers' compensation costs. J Occup Environ Med 2001; 43:672-9. [PMID: 11515249 DOI: 10.1097/00043764-200108000-00004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Previous studies evaluating workers' compensation care systems used retrospective controls. We performed a concurrent effectiveness study comparing a WC system that used visiting musculoskeletal specialists to assist primary care physicians with a typical discounted-fee, WC, managed-care system. In the new specialist-direct system, physicians could not profit from self-referral, but were paid 35% to 69% more per patient visit than doctors in the discounted-fee clinics. All claims filed by all employees of two hotels for 2 years were examined. Patients had self-selected either a specialist-direct or a discounted-fee clinic, and the entire cost of the claim was assigned to either system of care. Claim costs were 63% lower in the specialist-direct system (P < 0.001). Medical costs were 45% less (P < 0.014), and indemnity 85% less (P < 0.001), in this system. Claims were closed nearly 6 months faster in the specialist-direct system (P < 0.0001). Indemnity claims were more common in the discounted-fee system (P < 0.0001). Claimant and injury characteristics were not significantly different between the systems. This new care model is a cost-effective alternative to discounted WC managed care. Discounting the services of the primary treating physician may result only in cost-shifting, not cost-saving.
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Affiliation(s)
- S G Atcheson
- Arthritis Specialists of Northern Nevada, 93 Bell Street, Reno, NV 89503, USA
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Wootton R, Bloomer SE, Corbett R, Eedy DJ, Hicks N, Lotery HE, Mathews C, Paisley J, Steele K, Loane MA. Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis. BMJ (CLINICAL RESEARCH ED.) 2000; 320:1252-6. [PMID: 10797038 PMCID: PMC27370 DOI: 10.1136/bmj.320.7244.1252] [Citation(s) in RCA: 171] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Comparison of real time teledermatology with outpatient dermatology in terms of clinical outcomes, cost-benefits, and patient reattendance. DESIGN Randomised controlled trial with a minimum follow up of three months. SETTING Four health centres (two urban, two rural) and two regional hospitals. SUBJECTS 204 general practice patients requiring referral to dermatology services; 102 were randomised to teledermatology consultation and 102 to traditional outpatient consultation. MAIN OUTCOME MEASURES Reported clinical outcome of initial consultation, primary care and outpatient reattendance data, and cost-benefit analysis of both methods of delivering care. RESULTS No major differences were found in the reported clinical outcomes of teledermatology and conventional dermatology. Of patients randomised to teledermatology, 55 (54%) were managed within primary care and 47 (46%) required at least one hospital appointment. Of patients randomised to the conventional hospital outpatient consultation, 46 (45%) required at least one further hospital appointment, 15 (15%) required general practice review, and 40 (39%) no follow up visits. Clinical records showed that 42 (41%) patients seen by teledermatology attended subsequent hospital appointments compared with 41 (40%) patients seen conventionally. The net societal cost of the initial consultation was pound132.10 per patient for teledermatology and pound48.73 for conventional consultation. Sensitivity analysis revealed that if each health centre had allocated one morning session a week to teledermatology and the average round trip to hospital had been 78 km instead of 26 km, the costs of the two methods of care would have been equal. CONCLUSIONS Real time teledermatology was clinically feasible but not cost effective compared with conventional dermatological outpatient care. However, if the equipment were purchased at current prices and the travelling distances greater, teledermatology would be a cost effective alternative to conventional care.
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Affiliation(s)
- R Wootton
- Institute of Telemedicine and Telecare, Royal Hospitals Trust, Belfast BT12 6BA.
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Jansen JJ, Grol RP, Van Der Vleuten CP, Scherpbier AJ, Crebolder HF, Rethans JJ. Effect of a short skills training course on competence and performance in general practice. MEDICAL EDUCATION 2000; 34:66-71. [PMID: 10607282 DOI: 10.1046/j.1365-2923.2000.00401.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVES Evaluation of the efficacy of a short course of technical clinical skills to change performance in general practice. DESIGN Subjects were self-selected general practitioners (n=59) who were unaware of the study design. They were assigned to the intervention group (n=31) or control group (n=28) according to their preference for course date. The course covered four different technical clinical skills (shoulder injection technique, PAP-smear, laboratory examination of vaginal discharge, ophthalmoscopic control in diabetes mellitus). Main outcome measures used were pre- and post-training scores on a knowledge test of skills (60 multiple choice items), and pre- and post-training performance of procedures in practice using a log-diary covering 20 days. SETTING University of Maastricht, The Netherlands. SUBJECTS Self-selected general practitioners. RESULTS Competence, as measured by the knowledge test of skills, improved significantly as a result of the training and skills test scores were satisfactory after training. A significant effect on performance in practice was found for PAP-smear and shoulder injection technique, whereas no effect could be demonstrated for examination of vaginal discharge and ophthalmoscopic control in diabetes mellitus. CONCLUSIONS A good degree of competence is a necessary but not always sufficient condition for a physician to change his performance in practice. While some skills training seems adequate to bring about desired changes, for other skills more complex interventions are probably needed.
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Affiliation(s)
- J J Jansen
- Department of General Practice University of Maastricht, Maastricht, The Netherlands
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Affiliation(s)
- C van Weel
- Netherlands School of Primary Care Research, Department of General Practice, University of Nijmegen.
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