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PubMed2005

Implementation of a cardiac surgery report card: lessons from the Massachusetts experience.

Demand is increasing for public accountability in health care. In 2000, the Massachusetts legislature mandated a state report card for cardiac surgery and percutaneous coronary interventions. During the planning and implementation of this report card, a number of observations were made that may prove useful to other states faced with similar mandates. These include the necessity for constructive, nonadversarial collaboration between regulators, clinicians, and statisticians; the advantages of preemptive adoption of The Society of Thoracic Surgeons [STS] National Cardiac Database, preferably before a report card is mandated; the support and resources available to cardiac surgeons through the STS, the National Cardiac Database Committee, and the Duke Clinical Research Institute; the value of a state STS organization; and the importance of media education to facilitate fair and dispassionate press coverage. Some important features of report cards may vary from state to state depending on the legislative mandate, local preferences, and statistical expertise. These include the choice of a statistical model and analytical technique, national versus regional reference population, and whether individual surgeon profiling is required.

Data Collection↗
PubMed2004

The 2-week rule for patients with suspected breast cancer: what can be learnt by analysing policy documents?

The '2-week rule', introduced in the UK during 1999, represents a significant organisational change for referral of patients with suspected breast cancer. From an analysis of policy documents, a mixture of influences and agendas from different interest groups are apparent in the current working of the policy. These include political/modernisation agendas with a variety of aims including: reducing variation in care, efficient administration, reassuring patients, improving public confidence, earlier referral and lowering the threshold for referral to improve mortality figures. Specialist agendas, exemplified by the guidelines for referral under the policy but apparent in preceding specialist literature, represent an attempt to modify the working of the policy to ensure that high proportions of those women referred have breast cancer. The agendas of these interest groups are in conflict and have implications for the future development of this particular policy. Similar considerations are likely to apply more widely to other controversial health policy developments. It may be of value to identify the agendas of the groups responsible for the introduction of such policies, as well as the agendas of groups with influence on how the policy is actually implemented, and assess the areas of conflict.

Breast Neoplasms↗
PubMed2004

Voluntary or compulsory health care reform? The case of primary care organisations in Scotland.

Previous studies have suggested that voluntary reform of the delivery of primary care services is more likely to occur in affluent areas. Health system reforms that include voluntary participation of GPs may therefore lead to a two-tier service in terms of access to and utilisation of medical services. New primary care organisations in Scotland (local health care co-operatives) were introduced in 1999. These are groups of general practices and membership was voluntary. The aim of this study is to examine whether the voluntary nature of membership was likely to exacerbate or reduce inequalities in the provision of primary care services. Logistic regression analysis was used to identify differences in population, practice, and GP characteristics between general practices that have joined a co-operative and those that have not. The results indicated that practices located in deprived areas and covering populations with high levels of morbidity were more likely to join a co-operative. High workload decreased the probability of membership. General practices that found it difficult to obtain access to local authority residential care homes were more likely to join a co-operative. The number of fee claims for minor surgery sessions per whole-time equivalent GP increased the probability of membership. There is therefore some evidence indicating that general practices located in areas of high need are more likely to join a co-operative. This suggests that voluntary participation in these new primary care organisations may reduce rather than exacerbate inequalities in the provision of primary care.

Community Networks↗
PubMed2006

The evolution of outpatient commitment in the USA: from conundrum to quagmire.

Outpatient commitment (OPC), a major form of involuntary community-based treatment, has evolved in the United States on a state-by-state basis amidst a storm of controversy. The polarizing debate that has gone on intensely about OPC for the last two decades has all too often been devoid of data. This article reviews the various arguments pro and con about OPC, and then examines the research on the effectiveness of OPC. Since the newest data seem to support OPC as a useful tool in dealing with specific subpopulations of persons with chronic mental illness, the paper examines the question of whether OPC is a legitimate use of government power. The most extensive analysis of this question to date has occurred in the New York State Courts which have supported the New York State OPC statute, Kendra's Law. The paper concludes with an examination of the future of OPC in the states, calling in particular for further research into the question of determining to whom, from a clinical point of view, should OPC be delivered.

Community Mental Health Services↗
PubMed2006

Can epidemiological studies assist in the evaluation of community treatment orders? - The experience of Western Australia and Nova Scotia.

Epidemiological studies using administrative databases have several advantages over other methodologies in studying the effectiveness of compulsory community treatment such as community treatment orders (CTOs). We compared patients placed on CTOs in Western Australia with controls drawn from both within the jurisdiction and from another without this measure (Nova Scotia). Although in different countries, the mental health services in both jurisdictions share common characteristics. Notably, we were able to control for forensic history in our comparison within Western Australia. We analysed predictors of admission and number of bed-days using multiple, logistic or Cox regression as appropriate. Of the 274 subjects placed on a CTO, we were able to find controls for up to 96% (n=265). CTO placement was not associated with reduced admissions or mean bed-days, although there was a threshold effect with a reduced risk of inpatient stays exceeding 100 days. Outpatient contacts were significantly greater for the CTO group. However, we do not know whether the intensity of treatment, or its compulsory nature, effected outcome.

Case-Control Studies↗
PubMed2006

A qualitative analysis of the use of community treatment orders in Saskatchewan.

This study examined the opinions of patients who have been placed on a community treatment order (CTO), their relatives, mental health clinicians and representatives of community agencies about the use of CTOs in Saskatchewan. Patients were assessed using indepth interviews, while their relatives, mental health professionals and representatives of community agencies took part in facilitated focus groups. Patients had contradictory feelings about CTOs. Most experienced some degree of coercion while on the orders but many believed that CTOs provided necessary structure in their lives. Clinicians were more consistently positive but recognized the difficult choices in balancing the subject's right to self-determination with the benefits of a treatment order. Family members viewed CTOs as necessary to control a chaotic situation caused by the subject's limited insight.

Ambulatory Care↗
PubMed2006

The relationship between mandated community treatment and perceived barriers to care in persons with severe mental illness.

OBJECTIVE: In recent decades debate has intensified over both the ethics and effectiveness of mandated mental health treatment for persons residing in the community. Perceived barriers to care among persons subjected to mandated community treatment, and the possibility that fear of involuntary treatment may actually create or strengthen such barriers rather than dissolve them, are key issues relevant to this debate but have been little studied. This article explores the link between receipt of mandated (or "leveraged") community treatment and reasons for avoiding or delaying treatment reported by persons with severe mental illness. It also examines the potential moderating effect of social support on the association between mandated treatment experiences and barriers attributable to fear of involuntary commitment or forced treatment. METHOD: Data are presented from a survey of 1011 persons with psychiatric disorders being treated in public-sector mental health service systems in five U.S. cities. Logistic and negative binomial regression analyses were used to examine the association between mandated community treatment and perceptions of barriers to care, controlling for demographic and clinical characteristics. RESULTS: Across sites, 32.4% to 46.3% of respondents reported barriers attributed to fear of forced treatment. Whereas 63.7% to 76.1% reported at least one non-mandate-related barrier to care; the mean number of non-mandated barriers to care ranged from 1.6 to 2.3 (range 0-7). Between 44.1% and 59.0% of participants had experienced at least one type of leveraged treatment. Persons experiencing multiple forms of mandated treatment were more likely to report barriers to care in comparison to those not reporting mandated treatment. Findings also indicated that social support moderates the relationship between multiple leverages (three or four forms) and mandate-related barriers to care. CONCLUSIONS: Perceived barriers to care associated with mandated treatment experience have the potential to adversely affect both treatment adherence and therapeutic alliance. Awareness of potential barriers to care and how they interact with patients' perceived social support may lead to improved outcomes associated with mandated treatment.

Adolescent↗
PubMed2006

Involuntary outpatient treatment as "desintitutionalized coercion": the net-widening concerns.

In American jurisprudence, two justifications have traditionally been put forth to support the government's social control of persons with mental illness: police power and parens patriae. As public mental hospitals became less available as loci in which to exercise these functions, governments sought alternative means to achieve the same ends. One prominent but quite controversial means is involuntary outpatient treatment (IOT). While the concerns about IOT have been myriad, one often alluded to but never documented is that of "net-widening." That is, once IOT became available, it would be applied to an ever greater number of individuals, progressively expanding the margins of the designated population to whom it is applied, despite the formal standard for its application remaining constant. We tested the net-widening belief in a naturalistic experiment in Massachusetts. We found that net-widening did not occur, despite an environment strongly conducive to that expansion. At this time, whatever the arguments against IOT might be, net-widening should not be one of them.

Ambulatory Care↗
PubMed2006

Dilemmas for clinicians in use of Community Treatment Orders.

Clinicians who treat patients using Community Treatment Orders (CTOs) face many potential dilemmas in their relations with involuntary outpatients and the exercise of their powers. We compare the dilemmas identified in the literature with those reported by responsible clinicians in New Zealand (NZ). These clinicians experienced a number of well-known dilemmas, such as determining the right moment for a person's discharge from a CTO, but they seemed less troubled by some other difficulties than might be expected, usually because they considered involuntary outpatient treatment the best option for the patient or the best way to manage the risks involved. Further dilemmas were identified by the NZ clinicians that have not been widely discussed, concerning the proper scope of clinical authority over patients under CTOs and the decision to revoke involuntary outpatient status. In conclusion, some suggestions are made as to how clinicians might best manage the dilemmas involved.

Adult↗
PubMed2004

Effect of middle school entry requirements on hepatitis B vaccination coverage.

We examined hepatitis B immunization coverage in states with and without middle school entry vaccination requirements. Hepatitis B vaccination was initiated and completed more frequently in states with middle school mandates, although near-universal coverage was not obtained. Nonetheless, establishment of mandates in states without them could significantly reduce hepatitis B transmission.

Adolescent↗
PubMed2004

The impact of motivational interviewing on substance abuse treatment retention: a randomized control trial of women involved with child welfare.

Previous studies have supported the efficacy of Motivational Interviewing (MI) in increasing treatment engagement and retention among people with substance abuse disorders. However, few studies have assessed the impact of MI with coerced populations, particularly women referred to drug abuse treatment by child welfare due to prenatal drug use. Seventy-one such women who used drugs during pregnancy were randomly assigned to either receive three MI sessions or to watch two educational videos and participate in a home visit. Treatment retention group attendance and random urine analysis results were evaluated in these women during the first 8 weeks of treatment. No differences were found between the two conditions on these variables. Possible reasons for these negative findings are discussed, as are ideas for future research with coerced populations.

Adolescent↗
PubMed2005

Substance use disorder patients who are mandated to treatment: characteristics, treatment process, and 1- and 5-year outcomes.

A substantial number of patients with substance use disorders (SUDs) are mandated to treatment by the justice system. However, little is known about their characteristics and how they fare during treatment and in the longer term compared with nonmandated, justice-system-involved patients and patients not involved in the justice system. This prospective study (n=2,095) examined differences in pretreatment characteristics, treatment perceptions and satisfaction, during-treatment changes, and 1- and 5-year outcomes among these three types of patients and tested whether differences in pretreatment characteristics or during-treatment changes could help explain posttreatment outcome similarities or differences. Mandated patients had a less severe clinical profile at treatment intake, yet this did not account for their observed similar/better outcomes, which appeared because of the similar therapeutic gains made during treatment. Treatment perceptions and satisfaction were also comparable across groups. These findings appear to support the idea that judicial mandates can provide an opportunity for offenders with SUDs to access and benefit from needed treatment.

Adult↗
PubMed2006

Reasons for post registration learning: impact of the learning experience.

This exploratory study is the second stage of a multi-method approach to explore some of the reasons why registered nurses take part in formal and informal learning and higher education. Also under exploration is the extent to which their various learning experiences met their expectations. The sample consists of 25 registered nurses, randomly selected from a population (N=162) of 1st and 2nd Level nurses employed in public and private clinical settings, who have taken part in continuing education to obtain a Diploma or a Degree in Nursing. The data gathering was achieved by three focus group interviews. Formal learning included mandatory and non-mandatory in house teaching. Mandatory input was regarded as a self-protection measure by the employer, not related to personal development and with no perceived benefit on client care. Regarding the achievement of additional clinical competences, the overwhelming reason is to improve client care, although the motives of the employer and medical staff are viewed with some suspicion as a measure to saving doctors' time. Higher education pursuits appears to be triggered by a perceived need to increase the participants' level of existing knowledge in line with that of current students on placement, but adjustment to adult life transition period also appear to be an influencing factor. In terms of learning experiences, the relevance and quality of mandatory sessions came under criticism, whilst a measure of surprise was expressed at the unexpected benefits, at a personal and a professional level, gained by taking part in academic learning.

Adult↗
PubMed2005

Time-efficient strategies to ensure vaccine risk/benefit communication.

Vaccine risk/benefit communication is a mandatory requirement set forth by the National Childhood Vaccine Injury Act and is essential in enabling parents to make an informed decision about having their children vaccinated. This article is designed to improve vaccine risk/benefit communication in pediatric primary care. Current research related to previous efforts used to educate parents about vaccine safety are reviewed. Time-efficient strategies to improve vaccine risk/benefit communication are recommended. An example of an open communication letter and a list of reputable vaccine information resources are also provided.

Attitude to Health↗