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PubMed2004

What is the impact of consultant supervision on outpatient follow-up rate?

This study investigated the impact of consultants on recycling rates of patients in the ENT outpatient clinic. A retrospective case review of 4205 consecutive patients who attended ENT outpatient clinics of an UK teaching hospital over a 3-month period was conducted. There was a significant association between grade of medical staff and recycling rate of new patients, and also for review patients. Junior doctors have lower recycling rates in consultant-led clinics compared with clinics in the absence of consultants for both new patients (consultant-led 41.0%, without consultant 60.1%; P < 0.01) and old patients (consultant-led 48.9%, without consultant 65.0%; P < 0.01). Individual consultant's practice was reflected upon the overall recycling rate of the clinic as a whole (r = 0.94, P = 0.001). In conclusion, individual consultant's practice dictated recycling rate in the ENT outpatient clinic. Junior doctors were less likely to make follow-up appointments when directly supervised by their consultants.

Appointments and Schedules↗
PubMed2006

Impact of the role of nurse, midwife and health visitor consultant.

AIM: This paper describes the findings from one aspect of an evaluation study of the role of the nurse, midwife and health visitor consultant and the consultants' perceived impact of their role on services and patient care. BACKGROUND: The nurse, midwife and health visitor consultant role was established in 2000 in England to improve patient care, strengthen leadership and provide a clinical career opportunity for nurses, midwives and health visitors. An evaluative study was commissioned to report on the role 4 years after the new consultant posts were first established. METHOD: A multimethod evaluation was undertaken in 2002-2003 combining focus groups, telephone interviews and a comprehensive questionnaire survey of all the consultants in England. Four hundred and nineteen consultants responded to the questionnaire, 22 volunteered for the focus groups and 32 participated in the interviews. RESULTS: Nearly half (44%) the consultants who responded to the survey reported having a substantial impact on their service and 55% reported having some positive impact. High reported impact increased to 71% for those who had been in post for 2 years or longer. Consultants felt that they had been most successful in providing better support to staff, but only 10% said that they had a major impact on reducing unnecessary expenditure within the service. Factors associated with high levels of reported impact included engagement in a wide range of activities, perceived competence in the role and strong medical support. Those reporting most impact also reported the greatest dissatisfaction with salary. CONCLUSION: As consultants become more established in their posts, they are able to identify improvements in practice, service reconfiguration and educational advantages for staff. Our findings suggest that the true influence of these posts will become clearer over time as the impact of consultants on long-term organizational change becomes more apparent.

Achievement↗
PubMed2005

HIV nursing consultants: patients' preferences and experiences about the quality of care.

AIM AND OBJECTIVES: We were interested to find out how human immunodeficiency virus (HIV)-patients judge the quality of care received from their HIV nursing consultants, compared with the care delivered by HIV specialists and general practitioners. Furthermore, we were interested in how the opinions of HIV patients on the HIV nursing consultant compared with the opinions of patients with rheumatic diseases on the care they receive from their specialized nurses. BACKGROUND: The role of nurses has changed over the years. For patients with chronic diseases there seems to be an increasing role for nursing consultants in the delivery of care. In evaluating quality of care, patients' views are considered important especially for the chronically ill who can be seen as experts by experience. METHODS: Between February 1999 and June 2000, 250 patients, receiving care from both general practitioner and specialist, received a questionnaire [Quality of Care Through the Patient's Eyes (QUOTE)-HIV] to assess HIV-related quality of care, as perceived by them. Aspects were formulated as "importance" and "performance" statements. Items were scored on 4-point scales. A ratio score (R(ij) = P(ij)/I(ij)) was calculated by dividing the perceived performance score (P) of an individual patient (i), on a health service (j) by his importance score (I). A comparison was made with patients with rheumatic diseases by using data from the QUOTE-Rheuma. RESULTS: Patients judged the quality of care from the HIV nursing consultant as predominantly good. Five aspects showed an unfavourable ratio score (R < 1.0) which indicates room for improvement. On the dimensions "professional performance" and "attitude of the professional" the HIV nursing consultant scores between the general practitioner and the HIV specialist. Patients with rheumatic diseases seemed to be more satisfied than HIV patients with the care from their nurse consultant. CONCLUSIONS: The HIV nursing consultants have an important role in the care of patients infected with HIV. The HIV nursing consultants are judged as good and are ranked in between the general practitioner and the HIV specialist. Given the orientation towards a more integrated care for chronically ill patients, there should be more attention paid to the position of the HIV nursing consultant. RELEVANCE TO CLINICAL PRACTICE: In the Netherlands and in the United Kingdom there is a tendency to a greater degree of differentiation of tasks in health care. This study shows that there is room for a position like the nursing consultant and that this is highly valued by patients.

Adult↗
PubMed1998

Clinical consultations in an aboriginal community-controlled health service: a comparison with general practice.

Clinical consultation at Danila Dilba, an Aboriginal community-controlled health service in Darwin, were compared with consultations in Australian general practice. We described 583 consultations, using a questionnaire based on the International Classification of Primary Care. The methods were similar to those of the Australian Morbidity and Treatment Survey (AMTS) of consultations in Australian general practice undertaken by the University of Sydney Family Medicine Research Unit. Compared with Australian general practice consultations, consultations with Danila Dilba were more complex: more young patients, more new patients, more home visits, more problems managed, more new problems and more consultations leading to emergency hospital admission. Skin infections, diabetes mellitus, chronic alcohol abuse, rheumatic heart disease (or rheumatic fever) and chronic suppurative otitis media were much more commonly managed at study consultations at Danila Dilba than at consultations with general practitioners in the AMTS. Nearly all patients saw an Aboriginal health worker first, and nearly half the consultations were with Aboriginal health workers alone. The results suggest possible limitations of fee-for-item Medicare funding of Aboriginal community-controlled health services compared with existing block grant funding.

Adolescent↗
PubMed2003

Internet based consultations to transfer knowledge for patients requiring specialised care: retrospective case review.

OBJECTIVE: To assess whether transferring knowledge from specialists at centres of excellence to referring doctors through online consultations can improve the management of patients requiring specialised care. DESIGN: Retrospective case review of the first year of internet based patient initiated consultations between referring doctors and consulting specialists. SETTING: US teaching hospitals affiliated with an organisation providing internet based consultations. PARTICIPANTS: Doctors in various settings around the world engaging in internet based consultations with specialists. MAIN OUTCOME MEASURES: New recommendations for treatment, change in diagnosis, and turnaround time for consultation compared with time to see a specialist. RESULTS: 79 consultations took place. 90% (n=71) of consultations were for services related to oncology. 90% of consultations involved new recommendations for treatment. The most common recommendation was a new chemotherapeutic regimen (68%, n=54). Diagnosis changed in 5% (n=4) of cases. The average turnaround time was 6.8 working days compared with an average of 19 working days to see a comparable specialist. CONCLUSIONS: Internet based consultations between specialists at centres of excellence and referring doctors contribute to patient care through recommendations for new treatment and timely access to specialist knowledge. Although change in diagnosis occurred in only a few cases, the prognostic and therapeutic implications for these patients may be profound.

Adolescent↗
PubMed2003

What do hospital consultants value about their jobs? A discrete choice experiment.

OBJECTIVE: To examine the strength of hospital consultants' preferences for various aspects of their work. DESIGN: Questionnaire survey including a discrete choice experiment. SETTING: NHS Scotland. PARTICIPANTS: 2923 hospital consultants in Scotland. MAIN OUTCOME MEASURES: Monetary valuations or prices for each job characteristic, based on consultants' willingness to pay and willingness to accept extra income for a change in each job characteristic, calculated from regression coefficients. RESULTS: The response rate was 61% (1793 respondents). Being on call was the most important attribute, as consultants would need to be compensated up to pound 18,000 (30% of their average net income) (P < 0.001) for a high on-call workload. Compensation of up to pound 9700 (16% of their net income) (P < 0.001) would be required for consultants to forgo opportunities to undertake non-NHS work. Consultants would be willing to accept pound 7000 (12% of net income) (P < 0.001) in compensation for fair rather than good working relationships with staff, and pound 6500 (11% of net income) (P < 0.001) to compensate them for a shortage of staff. The least important characteristic was hours of work, with pound 562 per year (0.9% of their net income) (P < 0.001) required to induce consultants to work one extra hour per week. These preferences also varied among specific subgroups of consultants. CONCLUSIONS: Important information on consultants' strength of preferences for characteristics of their job should be used to help to address recruitment and retention problems. Consultants would require increased payment to cover more intensive on-call commitments. Other aspects of working conditions would require smaller increases.

Consultants↗
PubMed2005

Do consultants differ? Inferences drawn from hospital in-patient enquiry (HIPE) discharge coding at an Irish teaching hospital.

OBJECTIVE: To find out if there was a difference between hospital consultants, all trained in acute general medicine, in length of stay (LOS), re-admission rates, resource utilisation, and diagnostic coding, among patients admitted as emergencies to St James' Hospital (SJH) Dublin. METHODS: A retrospective analysis was performed of data on discharges from hospital, recorded in the hospital in-patient enquiry (HIPE) system, relating to 9204 episodes among 6968 emergency medical patients admitted to SJH between 1 January 2002 and 31 October 2003. For comparative analysis, four physician groups were defined consisting of gastroenterology (GI, n = 4), respiratory (n = 3), general internal medicine (GIM, n = 2), or specialty (n = 5). RESULTS: GIM consultants had the shortest LOS (median 5 days); GIM and respiratory consultants were less likely to have long stay patients (> 30 days, p<0.0001). Patients re-admitted under the same consultant had a longer LOS than those re-admitted under a different consultant (p<0.0001). Endoscopy and GI radiology investigations were used most by GI consultants, computed tomography of the thorax by respiratory, ECHO by respiratory and specialty, and computed tomography of brain by GIM and specialty consultants. GI diagnostic codings were more frequent with GI consultants (p<0.0001), respiratory diagnoses and malignancy with respiratory (p<0.0001 for both), diabetes and hypertension with specialty (p = 0.0017), and heart failure more with GIM consultants (p = 0.001). CONCLUSIONS: This study found that the HIPE database was very powerful in predicting differences between hospital consultants in LOS, re-admission rates, resource utilisation, and disease coding. It would be of interest to examine the extent to which protocols and guidelines could reduce such variations.

Consultants↗
PubMed2006

Ethnicity, socioeconomic deprivation and consultation rates in New Zealand general practice.

OBJECTIVES: To explore the relationship between ethnicity, socioeconomic deprivation and utilization of general practice. METHODS: Data routinely collected by New Zealand general practices in 2001 were analysed using generalized linear regression. RESULTS: The mean number of doctor consultations for registered individuals was 3.7 and the median 2. After adjusting for age, gender and area socioeconomic deprivation, people from Maori, Pacific, Asian and other-unspecified ethnic groups consulted general practitioners at similar rates or less frequently than European people. There was a significant positive trend between increasing deprivation and increasing rates of general practitioner (GP) consultation. The most-deprived groups had an approximately 30% higher rate of consultation than the least-deprived groups. There was a significant negative trend between nurse consultations and deprivation, with people from the most-deprived groups having a 29% lower frequency of nurse consultation. There was a different pattern of doctor consultation in the under-six age group, where a higher rate of patient subsidy was available, suggesting cost may be a barrier to doctor consultation for other age groups. CONCLUSIONS: In the general practices, in this study, the increasing rate of doctor consultations with increasing socioeconomic deprivation is consistent with increased need. However, the fact that adjusted Maori and Pacific utilization rates were not higher than those for people of European ethnic identity is a cause for concern in light of evidence that Maori health status is poorer than European, even after adjusting for deprivation. Further research is required to explore potential barriers to general practice consultation.

Adolescent↗
PubMed1982

Systemic consultation in a general hospital.

Consultation psychiatry has long offered the potential for psychiatrists to impact on the mental health of large numbers of individuals. However, workers in consultation psychiatry have often described it as a stressful, ungratifying experience. Over the last fifty years, since the initiation of consultation psychiatry, a series of models of consult work has been presented in the literature. These models have increasingly become more complex in the system of organization in which they operate. Moreover, there has been a constant movement toward viewing the function of the psychiatrist as intervening in behavior outside of the patient. After reviewing the history of consultation psychiatry, the authors conclude that a logical development would be a systemic model in which the entire hospital system is seen as the focus of consultation and in which the goal of the consultant's work is seen as creating a more open and flexible hospital system. The authors, therefore, describe a systemic model in which the potential crisis offered by any request for consultation work is seen as a tool for intervening with the hospital system. The difficulties of attaining the objectivity necessary for implementing a systemic intervention are discussed. A method of systemic diagnosis of the hospital is presented as well as a number of strategies of intervention with the hospital system. The authors conclude that using a systemic model (with the hospital as the focus of consultation) can lead to the development of a more comprehensive science of consultation which will lead to an increase of gratification for the psychiatrist and a more healthy functioning hospital system.

Adolescent↗
PubMed1996

Patient satisfaction with time use in audiological consultations.

An analysis of how time was used in and around 60 consultations was carried out for the purpose of exploring the relationship of time use to patient satisfaction. Sixty patients across two practice settings were surveyed, immediately following their interaction with the audiologist, regarding satisfaction with the consultation. Satisfaction was measured via: (1) a four-point scale, which yielded a satisfaction rating; and (2) a check list of satisfaction with 11 aspects of the consultation, which yielded a satisfaction score. Satisfaction ratings and scores were correlated significantly (rs = 0.76 corrected for ties, P = 0.0001). The majority of patients were either 'very satisfied' (63%) or 'satisfied' (31.6%) with the consultation experience. Temporal pictures of the consultations of 'very satisfied', 'satisfied' and 'dissatisfied' patients were clearly different. For the present sample it appeared that patient satisfaction ensued when the total consultation time was equal to or exceeded 0.6 of the sum of total consultation time and the time spent waiting at the clinic immediately prior to the consultation. Regression analyses showed that of the temporal variables studied, total consultation time (TCT) and the amount of time waiting immediately pre consultation (WT) contributed most to the variation in patient satisfaction ratings and scores. Forty-two per cent of the variance in satisfaction ratings and 36% of the variance in satisfaction scores could be explained by TCT/(WT + TCT).

Adult↗
PubMed1991

Variability in classification of consultations by content-based descriptors.

OBJECTIVE: To determine the reliability with which general practitioners use content-based descriptors of consultations. Our hypothesis was that there would be considerable variety in the opinion of general practitioners on the classification of consultations by descriptors. DESIGN: General practitioners in Newcastle, New South Wales, assessed videotaped consultations and the written consultation records by 12 general practitioners. SETTING: The medical faculty of the University of Newcastle and the general practitioners' own homes and offices. PARTICIPANTS: Twelve general practitioner participants were selected from consultation tapes recorded in 1983 by the Primary Care Research Group at the University of Newcastle. Thirty-nine observer general practitioners were randomly selected from a list of general practitioners practising in the Newcastle area maintained by the Hunter Postgraduate Medical Institute. Those whose videotapes had been selected were excluded. RESULTS: There were high levels of variation between assessments made from the original records and from viewing the tapes. Doctors varied greatly in their use of the descriptors. This variation included estimation of the duration of consultations and of the individual components of the consultation (history, physical examination, problems dealt with). No systematic relationships were found between any characteristics of the doctors and their ratings of consultations. CONCLUSIONS: There is potential for enormous variation in the use of content-based descriptors currently available in Australia. Observer general practitioners tended to underestimate the content of the consultations and overestimate the duration. It would be inappropriate to use the general practitioner patient record for audit of the content or difficulty of a consultation.

Adult↗
PubMed1999

Use of articulators in the United Kingdom by consultant orthodontists in planning orthognathic surgery.

This questionnaire survey aimed to investigate articulator use in orthognathic surgical planning by consultant specialists in the United Kingdom (UK). A total of 205 questionnaires was sent to all consultant orthodontists in the UK. One hundred thirty questionnaires were completed, representing a 63.4% response rate. Consultants had been in their post for a median of 10.5 years (range 0 to 30 years) with a mean of 11.3 (SD 8.4) surgical cases per year. When asked which cases had been planned on a semiadjustable articulator, two thirds of consultants (67.7%) planned maxillary single-jaw procedures, 45.4% planned mandibular single-jaw procedures, and 77.7% planned bimaxillary procedures. While 98.5% of consultants reported access to at least one type of articulator, 14.6% of maxillary single-jaw and 5.4% of bimaxillary surgery was not planned on any articulator. Twice as many consultants who had been in their post fewer than 11 years had been trained on a semiadjustable articulator, compared to those who had more than 11 years of experience. Semiadjustable articulators were the most popular for planning orthognathic surgery. Consultants with less than 11 years of experience completed more surgical cases each year and were more likely to have been trained on a semiadjustable articulator than consultants with more than 11 years of experience. However, no link exists between the age of the consultant and the type of articulator selected for planning; this suggests that more mature consultants have received further training on contemporary articulator systems since receiving their accreditation.

Dental Articulators↗
PubMedDate not supplied

Malpractice liability for informal consultations.

BACKGROUND: Informal ("curbside") consults are widely used by primary care physicians. These interactions occur in person, by telephone, or even by e-mail. Exposure to malpractice liability is a frequent concern of subspecialty physicians and influences their willingness to engage in this activity. To assess this risk, we reviewed reported judicial opinions involving informal consultation by physicians. METHODS: A search of the existing medical literature, and of the Westlaw national database was undertaken to identify reported judicial opinions involving informal physician consults that address whether informal consultations create a legal relationship between consulting specialist physicians and patients that gives rise to a legal duty of care owed by the consulting specialist to the patient. CONCLUSIONS: Courts have consistently ruled that no physician-patient relationship exists between a consultant and the patient who is the focus of the informal consultation. In the absence of such a relationship, the courts have found no grounds for a claim of malpractice. Malpractice risks associated with informal consultation appear to be minimal, regardless of the method of communication. While "informal consultation" is not a term used by the courts, the courts have applied a consistent set of criteria that help define the legal parameters of this activity.

Humans↗
PubMed2005

Comparison of disagreement and error rates for three types of interdepartmental consultations.

Previous studies have documented a relatively high rate of disagreement for interdepartmental consultations, but follow-up is limited. We reviewed the results of 3 types of interdepartmental consultations in our hospital during a 2-year period, including 328 incoming, 928 pathologist-generated outgoing, and 227 patient- or clinician-generated outgoing consults. The disagreement rate was significantly higher for incoming consults (10.7%) than for outgoing pathologist-generated consults (5.9%) (P = .06). Disagreement rates for outgoing patient- or clinician-generated consults were not significantly different from either other type (7.9%). Additional consultation, biopsy, or testing follow-up was available for 19 (54%) of 35, 14 (25%) of 55, and 6 (33%) of 18 incoming, outgoing pathologist-generated, and outgoing patient- or clinician-generated consults with disagreements, respectively; the percentage of errors varied widely (15/19 [79%], 8/14 [57%], and 2/6 [33%], respectively), but differences were not significant (P >.05 for each). Review of the individual errors revealed specific diagnostic areas in which improvement in performance might be made. Disagreement rates for interdepartmental consultation ranged from 5.9% to 10.7%, but only 33% to 79% represented errors. Additional consultation, tissue, and testing results can aid in distinguishing disagreements from errors.

Diagnostic Errors↗
PubMed1996

Contribution of consultants to care of compromised pregnancies.

Obstetricians often seek consultative services of other specialists in the management of compromised pregnancies. However, the extent of such consultations and the contribution of these consultants have not been addressed in the literature. This study is addresses the contribution of consultants to the care of complicated pregnancies at a tertiary care center. During the 2 1/2 years of this retrospective study, 2263 antepartum admissions were made for pregnancy complications. One hundred sixty-six of those patients were hospitalized 176 times and were treated by one or more consulting physicians for a consultation rate of 7.8%. Eighteen specialties were consulted, including 54 (32%) consultations from maternal fetal medicine, 44 (24%) from internal medicine, 28 (16%) from general surgery, and 22 (12%) from endocrinology. Of the initial admission diagnoses, 87.9% were confirmed and 46 new diagnoses were made by the consultants. A significant positive correlation was noted between the number of consultants, maternal length of hospital stay, and maternal hospitalization cost.

Adult↗
PubMed1996

[Geriatric consultations in a general hospital].

The increasing numbers of the elderly admitted to general hospitals, and the complexity of their problems, has increased the need for geriatric consultations. We evaluated geriatric consultations given at the Wolfson Medical Center by the geriatricians of Shmuel Harofeh Hospital. Data on 6-months of consultations in medical, surgical, urologic, neurologic, orthopedic and intensive care departments were evaluated. 7,910 elderly (65 years and over) were admitted during this period, representing 58% of all admissions; 742 (9.4%) were targeted for geriatric consultation. The largest number of consultations (525) were in the medical wards, but the highest rate of consultations was in the orthopedic ward for rehabilitation after operations for hip fractures. The selection of patients for geriatric consultation at Wolfson Hospital was done by the staff of each ward. This method differs from that in most general hospitals abroad, where selection is by geriatric teams. Despite this difference, our data show that the rates of consultations were similar. Also, the multidisciplinary teams consisted of members of the staff of each ward and the geriatric consultant. The method of geriatric consultations presented is easy to set up, simple to operate, efficient and appreciated by the medical staff of the departments.

Aged↗
PubMed2004

Cold weather and GP consultations for respiratory conditions by elderly people in 16 locations in the UK.

BACKGROUND: Cold weather is associated with increases in mortality and demands on hospital services in the UK, particularly by the elderly. Less is known about the relationship with patterns of consultation in primary care. We wished to determine the magnitude and consistency of associations between cold temperature and consultations for respiratory conditions in primary care settings at different sites in the UK. METHODS: Time series analysis of any short-term effects of temperature on daily general practitioner (GP) consultations made by elderly people (65+ years) for lower and upper respiratory tract infections (LRTI, URTI) over a 10-year period, 1992--2001. Practices were situated in 16 urban locations across the UK where a Met Office monitoring station was in operation. RESULTS: An association between low temperatures and an increase in LRTI consultations was observed in all 16 locations studied. The biggest increase was estimated for the Norwich practices for which a 19.0% increase in LRTI consultations (95% CI 13.6, 24.7) was associated with every 1 degrees C drop in mean temperature below 5 degrees C observed 0-20 days before the day of consultation. Slightly weaker relationships were observed in the case of URTI consultations. A north/south gradient, with larger temperature effects in the north, was in evidence for both LRTI and URTI consultations. CONCLUSIONS: An effect that was consistent and generally strongest in populations in the north was observed between cold temperature and respiratory consultations. Better understanding of the mechanisms by which cold weather is associated with increases in consultations for respiratory infections could lead to improved strategies for prevention and reduced burdens for health services.

Aged↗
PubMed1998

Gender differences in consulting a general practitioner for common symptoms of minor illness.

The aim of this paper is to examine whether, in response to the same symptoms of minor illness, women reported a greater propensity to consult a general practitioner than men. Respondents taking part in the West of Scotland Twenty-07 Study (853 aged 39 and 858 aged 58) were presented with a check-list of 33 symptoms during the course of a home interview conducted by nurses. They were asked whether they had experienced any of these symptoms in the last month, and if they had, whether they consulted a general practitioner about it. A summary indicator for reporting, or consulting for, at least one symptom was constructed, and statistical associations between gender, reporting and consulting for symptoms were examined using chi-square tests with Yates' correction. Women were more likely to have consulted a general practitioner for at least one of the 33 symptoms of minor illness reported in the previous month (34% of women, 27% of men aged 39, chi2 = 3.97, p < 0.05; 49% of women, 43% of men aged 58, chi2 = 3.21, (NS)). Women were significantly more likely to have consulted for five individual symptoms in the younger cohort, and for three symptoms in the older cohort, whilst men were significantly more likely to have consulted for only one symptom, in the younger cohort. However, when only those who had reported a symptom in the last month were included in analysis there were no gender differences in consulting for any of the 33 symptoms in the older cohort, and for just 3 symptoms in the younger cohort. These data do not support the most widely suggested explanation for gender differences in consulting, that once symptoms are perceived, women have a higher propensity to consult a general practitioner with the symptom than men.

Adult↗