Depression management programs
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Journal Article↗
Biomedical subjects
S Pearson
Publications and source records attributed to S Pearson.
Give families credit, access.
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Emergency Service, Hospital↗
Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial.
BACKGROUND: The provision of information before medical or surgical procedures should improve knowledge and allay anxiety about the pending procedure. This trial aimed to assess the value of an information video in this process. METHODS: Patients scheduled to undergo colonoscopy were approached about 1 week before the procedure. All patients were given an information leaflet about colonoscopy, and completed a Spielberger state anxiety inventory (STAI) questionnaire to assess baseline anxiety. The patients were then randomly assigned to watch or not watch the information video. Immediately before colonoscopy, all patients completed a second anxiety questionnaire and a knowledge questionnaire. FINDINGS: 198 patients were screened. 31 declined to participate and 17 were unable to complete the forms. Of the remaining 150 patients, 72 were assigned the video, and 78 no video. The groups were similar with regard to age, sex, educational attainment, and initial anxiety score. Female patients had higher baseline anxiety than male patients (mean STAI 46.3 [95% CI 44.9-47.7] vs 36.9 [35.5-38.3]; difference 9.4 [7.8-12.2], p=0.0008). Patients who had not had a previous colonoscopy had higher baseline anxiety scores than those who had prior experience of the procedure (46.9 [45.4-48.5] vs 36.3 [34.7-37.9]; difference 10.6 [7.5-13.8], p=0.0008). Patients who watched the video were significantly less anxious before colonoscopy than those who did not. The former also scored more highly in the knowledge questionnaire than the latter with regard to the purpose of the procedure, procedural details, and potential complications of colonoscopy. INTERPRETATION: An information video increases knowledge and decreases anxiety in patients preparing for colonoscopy.
Adult↗
Timeliness and quality of care for elderly patients with acute myocardial infarction under health maintenance organization vs fee-for-service insurance.
BACKGROUND: A commonly voiced concern is that health maintenance organizations (HMOs) may withhold or delay the provision of urgent, essential care, especially for vulnerable patients like the elderly. OBJECTIVE: To compare the quality of emergency care provided in Minnesota to elderly patients with acute myocardial infarction (AMI) who are covered by HMO vs fee-for-service (FFS) insurance. METHODS: We reviewed the medical records of 2304 elderly Medicare patients who were admitted with AMI to 20 urban community hospitals in Minnesota (representing 91% of beds in areas served by HMOs) from October 1992 through July 1993 and from July 1995 through April 1996. MAIN OUTCOME MEASURES: Use of emergency transportation and treatment delay (>6 hours from symptom onset); time to electrocardiogram; use of aspirin, thrombolytics, and beta-blockers among eligible patients; and time from hospital arrival to thrombolytic administration (door-to-needle time). RESULTS: Demographic characteristics, severity of symptoms, and comorbidity characteristics were almost identical among HMO (n = 612) and FFS (n = 1692) patients. A cardiologist was involved as a consultant or the attending physician in the care of 80% of HMO patients and 82% of FFS patients (P = .12). The treatment delay, time to electrocardiogram, use of thrombolytic agents, and door-to-needle times were almost identical. However, 56% of HMO patients and 51% of FFS patients used emergency transportation (P = .02); most of this difference was observed for patients with AMIs that occurred at night (60% vs 52%; P = .02). Health maintenance organization patients were somewhat more likely than FFS patients to receive aspirin therapy (88% vs 83%; P = .03) and beta-blocker therapy (73% vs 62%; P = .04); these differences were partly explained by a significantly larger proportion of younger physicians in HMOs who were more likely to order these drug therapies. All differences were consistent across the 3 largest HMOs (1 staff-group model and 2 network model HMOs). Logistic regression analyses controlling for demographic and clinical variables produced similar results, except that the differences in the use of beta-blockers became insignificant. CONCLUSIONS: No indicators of timeliness and quality of care for elderly patients with AMIs were lower under HMO vs FFS insurance coverage in Minnesota. However, two indicators of quality care were slightly but significantly higher in the HMO setting (use of emergency transportation and aspirin therapy). Further research is needed in other states, in different populations, and for different medical conditions.
Adrenergic beta-Antagonists↗
Prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure.
BACKGROUND: A single home-based intervention (HBI) applied immediately after hospital discharge in a cohort of "high-risk" patients with congestive heart failure has been shown to decrease numbers of unplanned readmissions plus out-of-hospital deaths during a period of 6 months. The duration of this beneficial effect remains uncertain. METHODS: Hospitalized patients with congestive heart failure who had been randomly assigned to receive either usual care (n=48) or HBI 1 week after discharge (n=49) were subject to an extended follow-up of 18 months. The primary end point of the study was frequency of unplanned readmissions plus out-of-hospital deaths. Secondary end points included total hospital stay, frequency of multiple readmissions, cost of hospital-based care, and total mortality. RESULTS: During 18-month follow-up, HBI patients had fewer unplanned readmissions (64 vs 125; P=.02) and out-of-hospital deaths (2 vs 9; P=.02), representing 1.4+/-1.3 vs 2.7+/-2.8 events per HBI and usual-care patient, respectively (P=.03). The HBI patients also had fewer days of hospitalization (2.5+/-2.7 vs 4.5+/-4.8 per patient; P=.004) and, once readmitted, were less likely to experience 4 or more readmissions (3/31 vs 12/38; P=.03). Hospital-based costs were significantly lower among HBI patients (Aust $5100 vs Aust $10600 per patient; P=.02). Unplanned readmission was positively correlated with 14 days or more of unplanned readmission in the 6 months before study entry (odds ratio [OR], 5.4; P=.006). Positive correlates of death were (1) non-English speaking (OR, 4.9; P=.008), (2) 14 days or more of unplanned readmission in the 6 months before study entry (OR, 4.9; P=.008), and (3) left ventricular ejection fraction of 40% or less (OR, 3.0; P=.03); conversely, assignment to HBI was a negative correlate (OR, 0.3; P=.02). CONCLUSIONS: In this controlled study, among a cohort of high-risk patients with congestive heart failure, beneficial effects of a postdischarge HBI were sustained for at least 18 months, with a significant reduction in unplanned readmissions, total hospital stay, hospital-based costs, and mortality.
Adult↗
Non-veridical size perception of expanding and contracting objects.
Observers were presented with various types of stimulus expansion and contraction which resulted in marked misperceptions of size. Firstly, the perceived size of an object which is changing in size is shown to be biased in the direction of the size change. Secondly, expansion or contraction of the internal texture of objects is found to influence their perceived size. Finally, an illusory texture manipulation in the form of a movement after-effect is shown to produce the same type of size misperception as a real expansion or contraction of internal texture. The spatio-temporal characteristics of these illusory size changes are investigated.
Humans↗
Ebola (subtype Reston) virus among quarantined nonhuman primates recently imported from the Philippines to the United States.
In April 1996, laboratory testing of imported nonhuman primates (as mandated by quarantine regulations) identified 2 cynomolgus macaques (Macaca fascicularis) infected with Ebola (subtype Reston) virus in a US-registered quarantine facility. The animals were part of a shipment of 100 nonhuman primates recently imported from the Philippines. Two additional infected animals, who were thought to be in the incubation phase, were identified among the remaining 48 animals in the affected quarantine room. The other 50 macaques, who had been held in a separate isolation room, remained asymptomatic, and none of these animals seroconverted during an extended quarantine period. Due to the rigorous routine safety precautions, the facility personnel had no unprotected exposures and remained asymptomatic, and no one seroconverted. The mandatory quarantine and laboratory testing requirements, put in place after the original Reston outbreak in 1989-1990, were effective for detecting and containing Ebola virus infection in newly imported nonhuman primates and minimizing potential human transmission.
Animals↗
Uncovering a multitude of sins: medication management in the home post acute hospitalisation among the chronically ill.
BACKGROUND: Sub-optimal use of prescribed medication is often associated with unplanned hospitalisation among the chronically ill. AIMS: To examine the extent of sub-optimal use of prescribed medication in a 'high risk' patient cohort recently discharged from acute hospital care. METHODS: Chronically ill patients discharged from acute hospital care (n = 342) were studied. At one week post discharge a home visit was performed by a nurse and a pharmacist during which medication management (including compliance and medication-related knowledge) was assessed. RESULTS: During the majority of home visits at least one medication-related problem was detected: approximately half of the cohort subject to a 'reliable' pill-count were found to be mal-compliant and almost all demonstrated inadequate medication-related knowledge. Mal-compliance was correlated with > or = five prescribed medications (Odds ratio [OR] 2.6: p < 0.002). Comparatively, lower medication-related knowledge was correlated with age > 75 years (OR 2.2: p < 0.001), exacerbation of a pre-existing chronic illness (OR 2.7: p = 0.044) and < or = six years formal education (OR 1.9: p = 0.004). Neither were modulated by extent of in-hospital counselling. Other previously unknown problems detected during the home visit included hoarding of previously prescribed medication (35%) and reducing medication intake to minimise costs (21%). CONCLUSIONS: Management of prescribed medications among chronically ill patients recently discharged from acute hospital care is often sub-optimal. Assessment of medication management in the home provides an invaluable opportunity to detect and address problems likely to result in poorer health outcomes.
Aged↗
Is health-related quality of life among older, chronically ill patients associated with unplanned readmission to hospital?
BACKGROUND: Assessment of health-related quality of life (HRQL) is being used increasingly to assess the impact of treatment. AIMS: To determine if HRQL, assessed shortly after acute hospitalisation, is associated with readmission to hospital. METHODS: In a prospective, longitudinal study, 163 chronically ill, medical and surgical patients (mean age 67.0+/-16.3 years) discharged to home following acute hospitalisation were studied. HRQL was assessed at one month post-hospital discharge using the MOS 36-Item Short-Form Health Survey (SF-36). Patients were followed-up for six months thereafter to determine subsequent incidence of unplanned readmission. RESULTS: HRQL as measured by the eight health dimensions of the SF-36, for the entire cohort, was lower relative to age and gender matched norms for the local population (p<0.01). During study follow-up, 47 (35%) patients had an unplanned readmission and one patient died. Patients who had an unplanned readmission demonstrated both significantly lower physical (32.2+/-9.8 vs 38.6+/-10.1: p<0.001) and mental (45.1+/-12.7 vs 49.9+/-12.3: p=0.03) health component scores in comparison to the remainder of the cohort. On multivariate analysis, independent correlates of unplanned readmission were: 1) presence of formal home assistance (OR 6.4: p<0.01), 2) > or =five prescribed medications (OR 2.4: p=0.04), 3) > or =two admissions in the six months before follow-up (OR 4.3: p<0.01) and 4) an SF-36 physical component score of < or =40 (OR 2.2: p=0.05). CONCLUSIONS: In this cohort of predominantly older and chronically ill patients recently discharged from acute hospital care, relatively lower SF-36 physical health component scores were independently associated with an increased risk of subsequent unplanned readmission.
Aged↗
Recurrent lung shadowing in adult juvenile idiopathic arthritis.
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Adult↗
Consultation between cardiologists and generalists in the management of acute myocardial infarction: implications for quality of care.
BACKGROUND: The rapid expansion of managed care in the United States has increased debate regarding the appropriate mix of generalist and specialist involvement in medical care. OBJECTIVE: To compare the quality of medical care when generalists and cardiologists work separately or together in the management of patients with acute myocardial infarction (AMI). METHODS: We reviewed the charts of 1716 patients with AMI treated at 22 Minnesota hospitals between 1992 and 1993. Patients eligible for thrombolytic aspirin, beta-blockers, and lidocaine therapy were identified using criteria from the 1991 American College of Cardiology guidelines for the management of AMI. We compared the use of these drugs among eligible patients whose attending physician was a generalist with no cardiologist input, a generalist with a cardiologist consultation, and a cardiologist alone. RESULTS: Patients cared for by a cardiologist alone were younger, presented earlier to the hospital, were more likely to be male, had less severe comorbidity, and were more likely to have an ST elevation of 1 mm or more than generalists' patients. Controlling for these differences, there was no variation in the use of effective agents between patients cared for by a cardiologist attending physician and a generalist with a consultation by a cardiologist. However, there was a consistent trend toward increased use of aspirin, thrombolytics, and beta-blockers in these patients compared with those with a generalist attending physician only (P<.05 for beta-blockers only). Differences between groups in the use of lidocaine were not statistically significant. The adjusted probabilities of use of thrombolytics for consultative care and cardiologist attending physicians were 0.73 for both. Corresponding probabilities were 0.86 and 0.85 for aspirin and 0.59 and 0.57 for beta-blockers, respectively. CONCLUSIONS: For patients with AMI, consultation between generalists and specialists may improve the quality of care. Recent policy debates that have focused solely on access to specialists have ignored the important issue of coordination of care between generalist and specialist physicians. In hospitals where cardiology services are available, generalists may be caring for patients with AMI who are older and more frail. Future research and policy analyses should examine whether this pattern of selective referral is true for other medical conditions.
Adrenergic beta-Antagonists↗
Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care.
BACKGROUND: We examined the effect of a home-based intervention (HBI) on readmission and death among "high-risk" patients with congestive heart failure discharged home from acute hospital care. METHODS: Hospitalized patients with congestive heart failure and impaired systolic function, intolerance to exercise, and a history of 1 or more hospital admissions for acute heart failure were randomized to either usual care (n=48) or HBI at 1 week after discharge (n=49). Home-based intervention comprised a single home visit (by a nurse and pharmacist) to optimize medication management, identify early clinical deterioration, and intensify medical follow-up and caregiver vigilance as appropriate. The primary end point of the study was frequency of unplanned readmissions plus out-of-hospital deaths within 6 months of discharge. Secondary end points included duration of hospital stay and overall mortality. RESULTS: During follow-up, patients in the HBI group had fewer unplanned readmissions (36 vs 63; P=.03) and fewer out-of-hospital deaths (1 vs 5; P=.11): 0.8+/-0.9 vs 1.4+/-1.8 (mean +/- SD) events per patient assigned to HBI and usual care, respectively (P=.03). Patients in the HBI group also had fewer days of hospitalization (261 vs 452; P=.05) and fewer total deaths (6 vs 12; P=.11). Patients assigned to usual care were more likely to experience 3 or more readmissions for acute heart failure (P=.02). Predictors of unplanned readmission were (1) 14 days or more of unplanned readmission during the 6 months before study entry (odds ratio [OR], 5.2; 95% confidence interval [CI], 1.8-16.2), (2) previous admission for acute myocardial ischemia (OR, 3.3; 95% CI, 1.2-9.1), and (3) an albumin plasma concentration of 38 g/L or less (OR, 2.4; 95% CI, 1.2-6.0). Home-based intervention was also associated with a trend toward reduced risk of unplanned readmission (OR, 0.4; 95% CI, 0.2-1.1). CONCLUSION: Among a cohort of high-risk patients with congestive heart failure, HBI was associated with reduced frequency of unplanned readmissions plus out-of-hospital deaths within 6 months of discharge from the hospital.
Acute Disease↗
Measuring the hospital experiences of junior doctors.
The development of an appraisal questionnaire which measures junior doctors' opinions about their hospital experiences is described. The first section of the questionnaire consists of seven reliable subscales which measure opinions about teaching and learning, registrar teaching, consultant teaching, staff support, workload, administration and overall experiences during a period of attachment or term. The second part of the survey contains 11 reliable questions about the hours spent on service and education during the term. The responses to this measure of 257 randomly selected Australian junior doctors are described. The questionnaire may be used to contrast the experiences of junior doctors in different types of terms, different hospitals or varying levels of training. The data generated from the instrument can provide useful information about hospitals, such as the work practices of junior staff and the effectiveness of educational programs.
Adult↗
A system for maintaining the educational and training standards of junior doctors.
The development of junior doctors' competence is complex because the hospital environment in which doctors work places many demands on them. The need for quality education and training and personal development may be in direct conflict with the service commitments required from hospitals. This paper describes the methods by which the Postgraduate Medical. Council of New South Wales, Australia, addresses the needs of junior doctors in the state in order to improve the quality of their education. Key elements of the Council's function include the provision of hospital clinical supervisors who oversee junior doctor education and training, and central involvement in supplying the junior doctor workforce to all state hospitals who must meet defined accreditation standards. This paper also provides data on evaluation of those methods and some educational outcomes.
Education, Medical, Graduate↗
Understanding the costs of ambulatory care training.
While patient care has been shifting to the ambulatory setting, the education of health care professionals has remained essentially hospital-based. One factor discouraging the movement of training into community-based ambulatory settings is the lack of understanding of what the costs of such training are and how these costs might be offset. The authors describe a model for ambulatory care training that makes it easier to generalize about to quantify its educational costs. Since ambulatory care training does not exist in a vacuum separate from inpatient education, the model is compatible with the way hospital-based education costs are derived. Thus, the model's elements can be integrated with comparable hospital-based training cost elements in a straightforward way to allow a total-costing approach. The model is built around two major sets of variables affecting cost. The first comprises three types of costs--direct, indirect, and infrastructure--and the second consists of factors related to the training site and factors related to the educational activities of the training. The model is constructed to show the various major ways these two sets of variables can influence training costs. With direct Medicare funding for some ambulatory-setting-based education pending, and with other regulatory and market dynamics already in play, it is important that educators, managers, and policymakers understand how costs, the characteristics of the training, and the characteristics of the setting interact. This model should assist them. Without generalizable cost estimates, realistic reimbursement policies and financial incentives cannot be formulated, either in the broad public policy context or in simple direct negotiations between sites and sponsors.
Ambulatory Care↗
Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths.
OBJECTIVE: To determine the effect of a home-based intervention (HBI) on the frequency of unplanned readmission and out-of-hospital death among patients discharged home from acute hospital care. DESIGN: A randomized controlled trial comparing HBI with usual care (UC). SETTING: A tertiary referral hospital servicing the northwestern region of Adelaide, South Australia. PARTICIPANTS: Medical and surgical patients (n = 762) discharged home after hospitalization. INTERVENTION: Home-based intervention (n = 381) consisted of counseling of all patients before discharge followed by a single home visit (by a nurse and pharmacist) to those patients considered to be at high risk of readmission (n = 314) in order to optimize compliance with and knowledge of the treatment regimen, identify early clinical deterioration, and intensify follow-up of such patients where appropriate. MEASUREMENTS: The primary endpoint was the number of unplanned readmissions plus out-of-hospital deaths over a 6-month follow-up period. RESULTS: During the study follow-up, the major endpoint occurred most commonly in the UC group (217 vs 155 episodes: P < .001). Overall, the HBI group demonstrated fewer unplanned readmissions (154 vs 197: P = .022), out-of-hospital deaths (1 vs. 20: P < .001), total deaths (12 vs. 29: P = .006), emergency department attendances (236 vs 314: P < .001), and total days of hospitalization (1452 vs 1766: P < .001). There was a disproportionate reduction in multiple events among HBI patients (P = .035). Hospital-based costs of health care during study follow-up tended to be lower in the HBI group ($A2190 vs $A2680 per patient: P = .102). Mean cost of HBI was $A190 per patient visited, whereas other community-based health care costs were similar for both groups. CONCLUSIONS: Among high-risk patients discharged from acute hospital care, HBI is beneficial in limiting unplanned readmissions and reducing risk of out-of-hospital death. It may be particularly cost-effective if applied selectively to patients with a history of frequent unplanned hospital admission.
Aged↗
Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.
OBJECTIVES: To investigate outcome, management, and prevention in Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. DESIGN: Ascertainment through British Paediatric Surveillance Unit and questionnaires to responding paediatricians. SETTING: The UK and Republic of Ireland, September 1992 to August 1994. SUBJECTS: Children under 14 years diagnosed with the above. MAIN OUTCOME MEASURES: Placement and child protection measures for victims and siblings; morbidity and reabuse rates for victims; abuse of siblings; prosecution of perpetrators. RESULTS: Outcome data for 119 with median follow up of 24 months (range 12 to 44 months). No previously diagnosed factitious disease was found to have been caused by genuine disease. Forty six children were allowed home without conditions at follow up. Children who had suffered from suffocation, non-accidental poisoning, direct harm, and those under 5 years were less likely to go home. Twenty seven (24%) children still had symptoms or signs as a result of the abuse at follow up; 108/120 were originally on a child protection register and 35/111 at follow up. Twenty nine per cent (34/118) of the perpetrators had been prosecuted and most convicted; 17% of the milder cases of Munchausen syndrome by proxy allowed home were reabused. Evidence in siblings suggests that in 50% of families with a suffocated child and 40% with non-accidental poisoning there would be further abuse, some fatal. CONCLUSIONS: This type of abuse is severe with high mortality, morbidity, family disruption, reabuse, and harm to siblings. A very cautious approach for child protection with reintroduction to home only if circumstances are especially favourable is advised. Paediatric follow up by an expert in child protection should also occur.
Adolescent↗
Images in clinical medicine. Endobronchial Kaposi's sarcoma.
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Adult↗