Barriers and enablers to implementing police mental health co-responder programs: A qualitative study using the consolidated framework for implementation research

Background

Police and mental health co-responder programs operate internationally and can be effective in providing timely and appropriate assessment, brief intervention, and referral services for people experiencing mental health crises. However, these models vary greatly, and little is known about how the design and implementation of these programs impacts their effectiveness.

Method

This study was a qualitative, post hoc implementation determinant evaluation of mental health co-responder units in Brisbane, Australia, comprising of verbal or written interviews with police and mental health staff with an on-road role in the co-responder units, and their managers. The Consolidated Framework for Implementation Research was used to identify barriers and enablers to the program's implementation and effectiveness.

Results

Participants (n = 30) from all groups felt strongly that the co-responder units are a substantial improvement over the usual police management of mental health crisis cases, and lead to better outcomes for consumers and the service. Enablers included an information-sharing agreement; the Mental Health Co-Responder (MHCORE) program's compatibility with existing police and mental health services; and the learning opportunity for both organizations. Barriers included cultural differences between the organizations, particularly risk-aversion to suicidality for police and a focus on least-restrictive practices for health; extensive documentation requirements for health; and a lack of specific mental health training for police.

Conclusions

Using an evidence-based implementation science framework enabled identification of a broad range of contextual barriers and enablers to implementation of police mental health co-responder programs. Adapting the program to address these barriers and enablers during the planning, implementation, monitoring, and evaluation phases increases the likelihood of the service's effectiveness. These findings will inform the spread and scale of the co-responder program across Queensland, and will be relevant to police districts internationally considering implementing a co-responder program.

“Always opening and never closing”: How dialogical therapists understand and create reflective conversations in network meetings

Tom Andersen’s reflecting team process, which allowed families to witness and respond to the talk of professionals during therapy sessions, has been described as revolutionary in the field of family therapy. Reflecting teams are prominent in a number of family therapy approaches, more recently in narrative and dialogical therapies. This way of working is considered more a philosophy than a technique, and has been received positively by both therapists and service users. This paper describes how dialogical therapists conceptualise the reflective process, how they work to engage families in reflective dialogues and how this supports change. We conducted semi-structured, reflective interviews with 12 dialogical therapists with between 2 and 20 years of experience. Interpretative Phenomenological analysis of transcribed interviews identified varying conceptualisations of the reflecting process and descriptions of therapist actions that support reflective talk among network members. We adopted a dialogical approach to interpretation of this data. In this sense, we did not aim to condense accounts into consensus but instead to describe variations and new ways of understanding dialogical reflecting team practices. Four themes were identified: Lived experience as expertise; Listening to the self and hearing others; Relational responsiveness and fostering connection; and Opening space for something new. We applied these themes to psychotherapy process literature both within family therapy literature and more broadly to understand more about how reflecting teams promote helpful and healing conversations in practice.

104 Assessing for Delirium in A District General Emergency Department—Why are We Failing and How can We Improve?

Introduction

Delirium is among the most common of medical emergencies with a prevalence of 20% in adult acute general medical patients. Despite this delirium is underdiagnosed and treatment is variable. Assessment of delirium is missed or carried out unreliably in EDs.

Methodology

Using the Model for Improvement, we developed a driver diagram to plan our project. Assessing whether patients over 65 years old were assessed for delirium during their visit to the ED using a validated tool over a 6-month period. Evaluating the impact of our interventions using annotated run charts. Exclusion criteria—GCS under 13, NEWS2 greater than 5.

Aim

Identify current performance of delirium assessment in over 65 s in Weston General Hospital ED and improve to 100% of over 65 s screened. Assess whether this has been communicated in the discharge summary.

Results

Baseline data showed 22.2% (4/18) of patients meeting inclusion criteria were screened for delirium. We implemented multiple interventions over a 2-month period—discussing at ED handover, hospital wide email, presentation at grand round and displaying a poster in the ED. In the 6 weeks after the interventions were implemented there was increase to 45.4% (15/33) of patients over 65 screened. Delirium/cognitive impairment identified in 42.5% (48/113) of patients screened. This is higher than the national average of hospital admissions therefore it is likely people screen those who display signs of delirium. Cognitive impairment communicated in discharge letter in only 29.4% (33/113) of all patients.

Conclusion

There has been a great improvement in delirium screening. However, we did not meet our target of 100% of patients being screened. Interventions currently being implemented—addition of SQID tool to minors clerking document, addition of compulsory tick box delirium question on all discharge summaries. Further data will be collected to assess effectiveness of these interventions.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

The rate, risk factors and cost of surgical site infections in primary breast surgery

Although breast surgery involving clean wounds is expected to be associated with a low risk of surgi-cal site infection (SSI) and minimal associated costs, estimates of infection could be affected by intensity of case finding and choice of follow-up methods. A broad range of post-discharge follow-up methods is more likely to estimate true SSI rates and costs. This prospective systematic study used 30 day surveillance with active data collection methods to identify the rate and cost of surgical site infection in patients having primary breast surgery. Ten per cent of patients (16/159) had a surgical site infection. The additional average cost of treating each infected patient was £1443. Hierarchical sequential regression identified high body mass index, operations lasting more than two hours and smoking as significant independent risk factors.

Psychiatric, cognitive and behavioural outcomes following craniopharyngioma and pituitary adenoma surgery

In order to determine the cognitive and behavioural changes in patients following craniopharyngioma surgery, all patients over the age of 16 years who had an operative intervention for craniopharyngioma between 1983 and 1998 were identified. Those consenting were interviewed using standardized instruments to assess for the presence of a psychiatric disorder, disturbance of behaviour or altered cognitive function. A control group of age- and sex-matched patients who had undergone pituitary adenoma excision were identically assessed. Eighteen people, of a total of 44, were interviewed. There were some differences in the subjective experience of appetite and the degree of control exercised over eating behaviour. Otherwise outcomes in cases and controls were similar. In the domains assessed, these two groups have similar outcomes from surgery.

Monitoring emergence from coma following severe brain injury in an octogenarian using behavioural indicators, electrophysiological measures and metabolic studies: a demonstration of the potential for good recovery in older adults

This case study describes a multi-disciplinary investigation of the emergence from coma of an 80-year old female (KE) following severe traumatic brain injury. The relationship between cognitive/behavioural ability and the integrity of cerebral function was assessed using neuropsychological measures, positron emission tomography, electroencephalography, somatosensory evoked potentials and trans-cranial magnetic stimulation. These investigations were performed as KE was beginning to emerge from coma (4 weeks) and, again, approximately 1 year following brain injury, when she was judged to have achieved her maximum level of recovery. Neuropsychological measures revealed improvement during the first year post-injury in KE's speed of information processing, memory and executive abilities. Electrophysiological and metabolic studies indicated a restoration of functional integrity that was consistent with the gradual recovery in higher brain function documented using behavioural procedures. This case study demonstrates the rehabilitation potential of pre-morbidly healthy older adults following severe traumatic brain injury.

Unilateral transplantation of human primary fetal tissue in four patients with Huntington's disease: NEST-UK safety report ISRCTN no 36485475

OBJECTIVES

Huntington's disease (HD) is an inherited autosomal dominant condition in which there is a CAG repeat expansion in the huntingtin gene of 36 or more. Patients display progressive motor, cognitive, and behavioural deterioration associated with progressive cell loss and atrophy in the striatum. Currently there are no disease modifying treatments and current symptomatic treatments are only partially effective in the early to moderate stages. Neural transplantation is effective in animal models of HD and offers a potential strategy for brain repair in patients. The authors report a safety study of unilateral transplantation of human fetal striatal tissue into the striatum of four patients with HD.

SUBJECTS AND METHODS

Stereotaxic placements of cell suspensions of human fetal ganglionic eminence were made unilaterally into the striatum of four patients with early to moderate HD. All patients received immunotherapy with cyclosporin A, azathioprine, and prednisolone for at least six months postoperatively. Patients were assessed for safety of the procedure using magnetic resonance imaging (MRI), regular recording of serum biochemistry and haematology to monitor immunotherapy, and clinical assessment according to the Core Assessment Protocol For Intrastriatal Transplantation in HD (CAPIT-HD).

RESULTS

During the six month post-transplantation period, the only adverse events related to the procedure were associated with the immunotherapy. MRI demonstrated tissue at the site of implantation, but there was no sign of tissue overgrowth. Furthermore, there was no evidence that the procedure accelerated the course of the disease.

CONCLUSIONS

Unilateral transplantation of human fetal striatal tissue in patients with HD is safe and feasible. Assessment of efficacy will require longer follow up in a larger number of patients.

Study of Cgrp-Receptors in Human Isolated Middle Meningeal Arteries Using Bibn4096Bs, Compound 1, and HαCgrp(8-37)

Calcitonin, CGRP, adrenomedullin, and amylin require both CRLR (calcitonin-gene receptor like receptor) and receptor activity modifying proteins (RAMP1, RAMP2, and RAMP3) in different combinations for expression of selective, functional receptors[1]. We investigated whether the antagonists BIBN4096BS[2], Compound 1 (WO98/11128, [3]), and CGRP(8-37) are functionally selective for CGRP receptors in human middle meningeal arteries (HMMA).

Investigation into the tribological condition of acetabular tissue after bipolar joint replacement hip surgery

The aim of this research was to investigate the tribological condition of acetabular tissue before and after bipolar hip surgery. Articular cartilage was taken from the femoral head of patients undergoing primary joint replacement as a control. Tissue was also taken from the acetabular cups of patients undergoing revision hip surgery after primary bipolar surgery and compared with the control cartilage. The biomechanical characteristics of the two tissue types were tested using friction and compression tests. The friction tests were carried out on a sliding friction rig under nominal contact stresses of 0.5 and 4 MPa. The compression tests were carried out under a 0.8 MPa contact stress. The majority of the bipolar patients produced friction coefficients that were significantly higher than those produced by the control group, and the compression tests highlighted that the tissue from the bipolar patients produced a much greater rate of increase in displacement compared with the control cartilage. Histology showed major differences between the control cartilage and the bipolar tissue. The control cartilage showed a healthy collagen structure with a good distribution of proteoglycan whereas the majority of the bipolar tissue had lost tissue architecture and had a sparse fibrous structure. The high friction coefficients with the bipolar tissue imply that the frictional torque at the outer head of the bipolar prosthesis would be large compared with the inner bearing frictional torque. It was therefore predicted that the motion of the bipolar prosthesis should occur at the inner bearing.

Non-random involvement of chromosome 13 in patients with persistent or relapsed disease after bone-marrow transplantation for chronic myeloid leukemia

Chronic myeloid leukemia (CML) patients with persistent or relapsed disease following bone-marrow transplantation (BMT) usually show both clonal and non-clonal cytogenetic changes in addition to the Philadelphia (Ph) translocation. These changes are presumably due to conditioning prior to transplantation and are generally not thought to be of clinical significance. We have examined the additional cytogenetic changes found in Ph+ve cells after BMT in 47 CML patients. Forty patients showed clonal changes. The involvement of each chromosome was compared statistically with expected values assuming that further chromosome changes are random and related to chromosome size. In clones that comprised 50% or more of the Ph+ve metaphases, chromosome 13 was involved in 12 of 22 clones (55%); this was highly significant when compared with the theoretical expected value of 3.2 (14.5%) (P < 0.001). The chromosome 13 rearrangements comprised both translocations and deletions. By means of FISH with a panel of 13q YAC clones, the breakpoints in 6 of these patients were investigated, but no common site of translocation was identified. The YAC panel was then used on material from 6 patients with chromosomal deletions. A common region of deletion was identified at 13q12-14, suggesting the presence of one or more tumor suppressor genes. We conclude that chromosome 13 deletions are non-randomly overrepresented in Ph+ve metaphases following BMT for CML. Genes Chromosomes Cancer 27:278-284, 2000.

Fusion of ETV6 to the caudal-related homeobox gene CDX2 in acute myeloid leukemia with the t(12;13)(p13;q12)

The t(12;13)(p13;q12) is a rare, recurrent translocation reported in a range of hematological malignancies. We have analyzed the molecular basis of this lesion in three patients with acute myeloid leukemia (AML), two of whom were known to have chromosome 12 breakpoints within the ETV6 gene. Fluorescence in situ hybridization (FISH) with ETV6 cosmids indicated that this gene was also disrupted in the third patient, while the normal ETV6 allele was retained. 3' rapid amplification of cDNA ends (RACE) polymerase chain reaction (PCR) from bone marrow mRNA of this individual identified a novel sequence fused to ETV6 that was homologous to a region just upstream of the mouse CDX2 homeobox gene, the human homologue of which has previously been mapped to chromosome 13q12. PCR primers designed to amplify an ETV6-CDX2 fusion identified two major transcripts from this patient. First, a direct in-frame fusion between exon 2 of ETV6 and exon 2 of CDX2, and second, a transcript that had an additional sequence of unknown origin spliced between these same exons. Surprisingly, apparently normal CDX2 transcripts, usually expressed only in intestinal epithelium, were also detectable in cDNA from this patient. Neither normal nor fusion CDX2 mRNA was detectable in the two other patients with a t(12;13), indicating that this translocation is heterogeneous at the molecular level. Reverse transcription-PCR analysis showed that CDX2 mRNA, but not ETV6-CDX2 mRNA, was strongly expressed in 1 of 10 patients with chronic myeloid leukemia in transformation, suggesting that deregulation of this gene may be more widespread in leukemia. CDX2 is known to regulate class I homeobox genes and its expression in hematopoietic cells may critically alter the balance between differentiation and proliferation.

Chromosomal breakage analysis in dyskeratosis congenita peripheral blood lymphocytes

Dyskeratosis congenita (DC) is a rare inherited disorder characterized by reticulate skin pigmentation, nail dystrophy and mucosal leucoplakia. Bone marrow failure occurs in the majority of cases and there is a predisposition to malignancy. Following conflicting reports of increased spontaneous and induced chromosomal breakage in DC lymphocytes, we examined chromosomal breakage with and without clastogen treatment in 10 DC patients from six different families. Peripheral blood cultures were stimulated with phytohaemagglutinin and treated with three clastogenic agents and gamma-irradiation. There was no significant difference in the chromosomal breakage in DC lymphocytes with or without exposure to bleomycin, DEB, MMC or gamma-irradiation. DC can therefore be distinguished from Fanconi's anaemia in which lymphocytes show increased spontaneous and clastogen-induced chromosomal breakage.

Investigation into the effect of proteoglycan molecules on the tribological properties of cartilage joint tissues

The aim of this research was to investigate the role of the hydrophilic properties of the proteoglycan molecules within the cartilage matrix, on the tribological properties of joint tissues in the mixed and boundary lubricating regime. Bovine articular cartilage, bovine meniscus and bovine cartilage that had been degraded to remove the chondroitin sulphate from its proteoglycans were studied in order to investigate differences in their friction and compression responses. The tissues were tested on a sliding friction rig under nominal contact stresses of 0.5 and 4 MPa. The compression tests were carried out under a 0.8 MPa contact stress. The compression tests showed the cartilage and meniscus deforming at the same rates, but the degraded cartilage deformed more quickly to reach its equilibrium position in a shorter period of time. The friction tests carried out at a constant load revealed the friction of the meniscus rising more rapidly with loading time than the cartilage. The degraded cartilage followed an almost identical curve as the untreated cartilage. Although the reduced proteoglycan content of the degraded cartilage substantially altered the biphasic compression response, it did not have an effect on the frictional properties of the tissue.

Guidelines for treatment of head injury in adults. Opinions of a group of neurosurgeons

There are a number of parallel activities world wide to devise guidelines for the treatment of head injuries. A Group of neurosurgeons from various European countries worked on guidelines during three informal meetings, which may serve as a base for discussion of national or local protocols. Three levels of certainty were distinguished: Measures that must be taken which such a high degree of certainty, that they have not seriously been challenged-principles. Measures, that should be taken, as there is reasonable evidence in the literature about its efficacy-recommendations and measures that may be taken, but proof of its efficacy is lacking-optional measures. Protocols based on these guidelines are felt to help young neurosurgeons in training, define neurosurgical needs for other specialities and enhance the general efficacy of care for the head injured patient including multiple injuries.

Controversies in thromboembolic disease during pregnancy: a critical review

OBJECTIVE

To critically appraise the body of literature concerning strategies for the prevention of thromboembolism during pregnancy.

DATA SOURCES

We used the Medline data base and reference lists of articles to identify all English-language papers examining thromboembolism during pregnancy.

METHODS OF STUDY SELECTION

We identified 156 articles in the obstetric literature and 29 articles in the medical literature that referenced nonpregnant populations. Together, these articles form the primary data base on which most recommendations are based.

DATA EXTRACTION AND SYNTHESIS

There are no level 1 trials (large randomized trials with definitive results) in the obstetric literature examining the efficacy of thromboembolism prophylaxis during pregnancy. There are only two level 2 trials (small randomized trials with uncertain results because of moderate to high alpha or beta error) that address prophylactic strategies in pregnant women with histories of thromboembolism or the antiphospholipid antibody syndrome. The remainder of the published trials are observational, some prospective but predominantly retrospective. Many of the recommendations from consensus panels regarding prophylactic strategies in pregnancy were based on level 1 trials in nonpregnant populations.

CONCLUSION

Although women with a history of thromboembolic disease are at appreciable risk of recurrence during pregnancy, the exact incidence is unknown and there are no adequate efficacy trials demonstrating that prophylactic regimens are effective. Heparin is the anticoagulant of choice in pregnancy; however, changes in metabolism and clearance make adequate dosing problematic. Expert consensus panels disagree over the optimal management of pregnant women at risk for thromboembolism. Randomized controlled trials during pregnancy are needed if any progress is to be made in combating this lethal disorder.

Computerised transient hyperaemic response test--a method for the assessment of cerebral autoregulation

A simple bedside test has been developed to assess the state of autoregulation in subarachnoid haemorrhage patients. Transcranial Doppler was used to measure blood flow velocity in the middle cerebral artery after a brief common carotid compression. Acceleration of blood flow postcompression was interpreted as evidence of intact cerebral autoregulation. A program using the Windows environment was designed for signal analysis of the transient hyperaemic response test (THRT). The flow velocity signal from the TCD was recorded, carotid compression and release automatically detected and the test results immediately displayed and stored in a database. The program was verified in 614 tests; 552 of them were analysed off-line using previously recorded data and 62 on-line during the examination. A significant correlation was found between the results of computerised testing and the patient's neurological state.

Assessment of cerebral autoregulation with ultrasound and laser Doppler wave forms--an experimental study in anesthetized rabbits

The aim of the study was to correlate changes in transcranial Doppler blood flow velocity wave form in the basilar artery with cortical red blood cell flux measured with a laser Doppler flowmeter during hemorrhage-induced hypotension in anesthetized and ventilated New Zealand rabbits. Although systolic flow velocity and flux exhibited an autoregulatory threshold at 45 mm Hg, diastolic flow velocity started to fall when mean arterial blood pressure fell below 65 mm Hg. The difference between the mean arterial blood pressure at which diastolic blood flow velocity decreases and the pressure at which mean flux decreases is the difference between systolic and diastolic blood pressure. The increasing divergence between systolic and diastolic flow velocities was reflected in an increase in the amplitude of blood flow velocity pulsations and pulsatility indices. An increase in flux pulsatile wave form was noted as cerebral resistive vessels dilated with hypotension.

Symmetry of cerebral blood flow and cognitive responses to hypoglycaemia in humans

A low blood glucose level is associated with impairment of higher cerebral function and an increase in cerebral blood flow. This study examined whether there are differences in the physiological responses to hypoglycaemia between the cerebral hemispheres. Eight healthy men participated in two hyperinsulinaemic glucose clamp studies: after 60 min at 4.5 mmol/l, blood glucose was either lowered to 2.0 mmol/l and "clamped" there for 60 min (hypoglycaemia) or continuously maintained at 4.5 mmol/l (euglycaemia). Cardiac output, middle cerebral artery velocity (transcranial Doppler) and cerebral blood flow (133-xenon inhalation) were measured during the studies. Neuropsychological tests were used to determine whether hypoglycaemia caused differential impairment of hemispheric cognitive function. Hypoglycaemia was associated with symmetrical impairment of cognitive function in both cerebral hemispheres and a rise in cardiac output (from 5.5 [0.2] to 8.7 [0.2] l.min-1, p < 0.0001, mean [standard error]), middle cerebral artery velocity (from 55 [2.6] to 64 [2.8] cm.s-1, p < 0.002), and global cerebral blood flow (from 56 [2.6] to 69 [2.9] ml.100 g-1.min-1, p < 0.005 compared to pre-insulin values). There were no differences in the blood flow response during hypoglycaemia between hemispheres and the increase in blood flow did not correlate with either the change in cardiac output or rise in plasma catecholamine levels. After 120 min of hyperinsulinaemic, euglycaemia, global cerebral blood flow rose significantly above baseline (from 58 [2.4] to 63 [2.2] ml.100 g-1.min-1, p < 0.05). In conclusion, using the techniques described, the physiological and cognitive responses of each cerebral hemisphere to hypoglycaemia were symmetrical.(ABSTRACT TRUNCATED AT 250 WORDS)

The hyperaemic response to a transient reduction in cerebral perfusion pressure. A modelling study

A mathematical model of cerebral blood flow and the cerebrospinal fluid circulation is described which permits the study of phenomena caused by dynamic changes in cerebrovascular autoregulatory or cerebrospinal fluid compensatory reserves. A transient decrease in cerebral perfusion pressure was produced by carotid artery compression. Comparison of the computer simulations with clinical and experimental data, reported elsewhere, suggests that the transient hyperaemic response (THR) is proportional to the strength of the autoregulatory response. The relationships between the magnitude and time course of the THR, and the period and level of reduction in CPP were studied. This model suggests that simple clinical tests based on the examination of THR using transcranial Doppler velocity measurements are of potential value for the non-invasive assessment of the autoregulatory reserve.

Technological Change in Fences and European Pastoral Heritage in Semi-Arid New South Wales

Despite increasing attention to conservation of natural resources and Aboriginal heritage, relics of the European pastoral industry in the semi-arid rangelands have been neglected. Fences are ubiquitous relics of the pastoral industry and show a rich variety in styles, techniques and technological change. Examples from Wilcannia in western New South Wales illustrate the variety that can be found. Legislation in New South Wales prohibits disturbance of relics (items > 50 years old) but has not been applied. The key step is assessing the significance of the item or place. Criteria adopted under The Burra Charter are listed and briefly discussed. Costs of conservation should be borne by society, not individual graziers; and grazier cooperation is essential for conserving cultural heritage.

Reversible cortical blindness as a complication of rheumatoid arthritis of the cervical spine

A case is presented in which a patient with rheumatoid damage to the cervical spine causing cervical cord and vertebral artery compression sustained transient cortical blindness with a partial left hemiparesis. Magnetic resonance imaging revealed anterior subluxation of middle cervical vertebrae, separation of the odontoid peg with resultant atlantoaxial subluxation, and proliferative pannus formation. The patient was almost symptom-free after transoral decompression and posterior cervical fusion.

Preventive care in diabetes mellitus. Current practice in urban health-care system

Early identification and treatment of complications of diabetes mellitus may reduce the severity of the complications. As part of a program to reduce these complications in the Denver Department of Health and Hospitals patient population, our study determined how frequently preventive care, e.g., fundoscopic examinations, referral to an ophthalmologist, foot examinations, and assessment of cardiovascular risk factors, was provided to diabetic patients. With the use of billing records to identify a large sample of diabetic patients, a chart review of 544 patients was conducted. During the study year, the mean +/- SE number of visits to primary-care clinics was 5.7 +/- 0.22, with 86.4% having at least one visit. Most diabetic patients were seen by primary-care physicians; only 9% received care in a specialized diabetes clinic. Despite frequent primary-care visits, most diabetic patients in this county health-care system did not have documentation of care to detect complications of diabetes mellitus, and referral services for detection and treatment of these complications were infrequently used. Moreover, among patients seen on greater than or equal to 10 occasions in a primary-care setting, preventive care was not provided to 30% of the patients. Preventive care does not appear to be a regular part of a primary-care visit for most of the diabetic patients in this study.