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Patient views on quality care in general practice: literature review.

The present paper examines research on patient satisfaction and the factors which influence patient attitudes regarding quality in general practice. Although data are used from U.S. and other sources, conclusions are drawn with a specific focus on a U.K. general practice context. This is a research area with a growing literature, much of it based on unsystematic research. The purpose of this paper is to make a contribution to the process or ordering the data in a manner which will be of utility to those involved in the provision of healthcare and the assessment of that provision. The data suggest conclusions in two broad areas: (1) methods by which patient satisfaction may be assessed; specific published instruments are reviewed, and (2) factors which have been indicated, by the research to date, to influence patient satisfaction. Most consistently identified as being of particular value to patients are interpersonal skills on the part of the practitioner. It is suggested that such techniques should receive wider acknowledgement as a basic element of the practitioner's technical repertoire.

Data Collection↗

Improving foot care for people with diabetes mellitus--a randomized controlled trial of an integrated care approach.

AIMS: To evaluate a model of integrated diabetic footcare, for identification and clinical management of the high risk diabetic foot, centred on the primary care-based diabetic annual review. METHODS: A pragmatic randomized controlled study was undertaken with matched cluster randomization of practices from 10 towns drawn from mid and east Devon responsible for the care of 1,939 people with diabetes (age > or =18 years). Outcome measures were patients' attitudes regarding the value and importance of footcare, patients' footcare knowledge, healthcare professionals' footcare knowledge and pattern of service utilization. RESULTS: Attitudes towards footcare improved in both intervention and control groups (mean percentage change 3.91, 0.68) with a significant difference in change of 3.18 (95% confidence interval (CI) 1.29-5.07) between the groups. Patients' knowledge about diabetic foot problems improved significantly in both groups (mean percentage change 1.09, 1.32) but with no significant difference in change: -0.09 (95% CI -1.81-1.63) between groups. Health professionals' knowledge scores improved in the intervention group (mean percentage change 13.2; P < 0.001). No improvement was seen in the control group (mean percentage change -0.2; P = 0.1) with a significant difference in change of 13.46 (95% CI 8.30-18.62) between groups. Appropriate referrals from intervention practices to the specialized foot clinic rose significantly (P = 0.05) compared with control practices (P = 0.14). CONCLUSIONS: Provision of integrated care arrangements for the diabetic foot has a positive impact on primary care staffs' knowledge and patients' attitudes resulting in an increased number of appropriate referrals to acute specialist services.

Adult↗

Rehabilitation service utilization and determinants among people with an intellectual disability: preliminary findings in Taiwan.

Improving rehabilitation services for people with intellectual disabilities (ID) remains an ongoing challenge in the public health system. The purpose of this article was to investigate the types of rehabilitation services used by people with ID and determine what factors predict resource utilization in Taiwan. Samples of 957 people with ID were recruited from the Taiwan National Disability Register in a cross-sectional study in 2001. The findings indicated that 24.5% of individuals with ID had received rehabilitation services in the past 7 months. The main types of services used were speech and communication therapy (50%), psychotherapy (32.1%), occupational therapy (30.3%) and physiotherapy (25.2%). Stepwise logistic regression was carried out for the utilization of rehabilitation services (yes/no). The model revealed that the following factors: (i) Major Illness Card holder, (ii) time spent in medical care, (iii) having a family physician, (iv) having illnesses, (v) age of ID individual, and (vi) gender of the main carer, were all significantly associated with the utilization of rehabilitation services. We should reorient the healthcare system to respond adequately to the health needs of rehabilitation service users and its determinants, and further research should focus on the effectiveness and efficiency of rehabilitation for people with ID in Taiwan.

Adolescent↗

Impact of duty hour restrictions on otolaryngology training: divergent resident and faculty perspectives.

OBJECTIVES: In 2003, the Accreditation Council for Graduate Medical Education (ACGME) passed a controversial mandate limiting resident work hours. We sought to examine the impact of these restrictions on otolaryngology programs and to explore faculty and resident perspectives. METHODS: Faculty and residents of all 102 ACGME-accredited otolaryngology residency programs were invited to participate in an anonymous online survey. RESULTS: The study population consisted of 460 respondents: 275 residents and 185 faculty (including 41 program directors) representing 57 otolaryngology programs. Sixty-five percent of programs implemented at least one change specifically to comply with duty-hour restrictions. Strategies included tracking work hours electronically (35.7%), utilization of "home call" (33.1%), and hiring additional healthcare professionals (23.1%). When asked if the restrictions have had a negative effect on patient care, 61% of respondents said no, but a surprising 33% said yes. Sixty-nine percent of faculty felt that the restrictions have actually had a negative effect on resident training compared with only 31% of residents (P<.001). Thirty-nine percent of participants felt resident workload was excessive before the restrictions. Opinions on whether duty-hour limits had fostered improvements in resident education, research, or examination scores varied, but most agreed that resident mental health had improved (67%). CONCLUSIONS: Otolaryngology programs have successfully restricted resident duty hours through significant infrastructural changes. Of concern, the majority of residents surveyed appeared to be in favor of the ACGME restrictions, whereas most program directors and faculty were opposed. Further studies are needed to establish whether limited work hours will enhance or hinder the residency training experience.

Adult↗

Accountability framework for managing stakeholders of health programs.

Understanding the incentives of stakeholders and employing effective management practices with various stakeholder groups is essential for program sustainability. This paper offers a conceptual model that depicts four different types of stakeholder interests that are relevant to health service organizations. The study identified the major stakeholders of telehealth programs, compared the influence of stakeholders by organizational ownership and investigated the practices used to manage these stakeholders. Quantitative and qualitative analyses demonstrated empirical support for the stakeholder model. The paper suggests that the model can be used as a stakeholder management tool in healthcare organizations and offers an assessment of the utility of the stakeholder framework in organizational research

Health Services Administration↗

Ensuring quality information for patients: development and preliminary validation of a new instrument to improve the quality of written health care information.

BACKGROUND: Despite the recent focus on improving the quality of patient information, there is no rigorous method of assessing quality of written patient information that is applicable to all information types and that prescribes the action that is required following evaluation. OBJECTIVE: The aims of this project were to develop a practical measure of the presentation quality for all types of written health care information and to provide preliminary validity and reliability of the measure in a paediatric setting. METHODS: The Ensuring Quality Information for Patients (EQIP) tool was developed through a process of item generation, testing for concurrent validity, inter-rater reliability and utility. Patient information managers and health care professionals tested EQIP in three annual audits of health care leaflets produced by a children's hospital. RESULTS: The final tool comprised 20 items. Kendall's tau B rank correlation between EQIP and DISCERN was 0.56 (P = 0.001). There was strong agreement between intuitive rating and the EQIP score (Kendall's tau B = 0.78, P = 0.009). Internal consistency using Cronbach's alpha was 0.80. There was good agreement between pairs of raters (mean kappa = 0.60; SD = 0.18) with no differences based on types of leaflets. Audits showed significant improvement in the number of leaflets achieving a higher quality EQIP rating over a 3-year period. CONCLUSIONS: EQIP demonstrated good preliminary validity, reliability and utility when used by patient information managers and healthcare professionals for a wide variety of written health care information. EQIP uniquely identifies actions to be taken as a result of the quality assessment. Use of EQIP improved the quality of written health care information in a children's hospital. Wider evaluation of EQIP with written information for other populations and settings is recommended.

Humans↗

Efficacy of colony-stimulating factors in acute leukemia.

OBJECTIVE: To evaluate the literature describing the safety and efficacy of the hematopoietic colony-stimulating factors (CSFs) for the management of treatment-related adverse effects in patients with acute leukemia. DATA SOURCES: A systematic MEDLINE search of the English-language literature (1995-April 2000) was performed to identify all randomized trials evaluating CSF use in acute leukemia. The following search terms were used: granulocyte colony-stimulating factor, filgrastim, granulocyte-macrophage colony-stimulating factor, sargramostim, acute lymphoblastic leukemia (ALL), acute myelogenous leukemia (AML), acute nonlymphocytic leukemia, and acute myeloid leukemia. The references from relevant literature were also examined in order to identify reports not discovered in the MEDLINE search. DATA SYNTHESIS: Six randomized trials in pediatric ALL, nine in adult AML, and four in adult ALL have examined the safety and efficacy of the CSFs. Two of the pediatric trials supported a reduction in either the duration of hospitalization or in the incidence of febrile neutropenia when a CSF was employed during the consolidation or intensification phase of chemotherapy. The remaining pediatric trials failed to demonstrate a clinical benefit. In adult AML, eight of the nine trials showed a significant decrease in the time to neutrophil recovery when a CSF was used. Only one of these trials demonstrated a decrease in hospital stay and none showed a decreased incidence of infection for patients who received a CSF. Three of the four trials in adult ALL demonstrated the efficacy of a CSF in decreasing the number of days to neutrophil recovery. Only one trial demonstrated that a CSF led to a reduction in the number of hospital days. Trials in children or adults have not demonstrated that the CSFs influence the long-term outcome of patients with acute leukemia. CONCLUSIONS: The published studies document a decrease in the time to recovery from neutropenia when patients with acute leukemia are treated with a CSF. However, a consistent reduction in infectious complications or in the duration of hospitalization has not been demonstrated when a CSF is used for either pediatric or adult patients. Very limited data exist to support the premise that CSFs meet the criteria established by the American Society of Clinical Oncology for demonstrating the value of these agents. Further careful study focused on resource utilization and pharmacoeconomics may help to elucidate how healthcare institutions may most effectively employ CSFs to treat patients with acute leukemia.

Acute Disease↗

Practical guidelines on the postoperative use of patient-controlled analgesia in the elderly.

Inadequate pain control after surgery is associated with adverse outcomes in elderly patients; for this reason, effective analgesia is an essential component of postoperative care in this patient group. However, postoperative pain management is challenging in the elderly because of concomitant disease states and physiological factors that can affect the pharmacodynamic and pharmacokinetic properties of analgesic drugs. Patient-controlled analgesia (PCA) offers advantages over traditional intramuscular analgesia in this setting, because it provides the opportunity to tailor therapy to the individual, as opposed to the average, patient. Morphine is the most widely used, and presently the most suitable, drug for use in PCA in the elderly. Studies have indicated that, after acute pain has been brought under control, PCA should be initiated at a dose of 1 or 1.5mg per dose, with a lockout period of 5 to 7 min. Continuous background infusions of opioids are contraindicated. Education of patients and healthcare professionals alike is necessary to optimise the utility of PCA in older patients. In addition, every effort should be made to avoid the development of postoperative confusion, as this is associated with an increased risk of inefficient pain relief and its deleterious consequences. In summary, close monitoring and evaluation of the patient throughout the peri-operative periods is required to ensure the appropriate and successful use of PCA in elderly patients.

Aged↗

Managing financial risk with options on futures.

With the rise of managed care and capitation, more providers will be sharing in the financial risk of providing care. To help protect their organizations from the risk of unexpectedly high utilization under such a fixed-payment system, healthcare financial managers soon will be able to use options on futures contracts. These contracts provide wide profit potential but limited loss potential. Before investing in options on futures, however, healthcare financial managers should consider issues such as basis risk and trading costs.

Capitation Fee↗

Modern health care depends on technology, Part 2.

The first article in this series presented the principles and vocabulary of technology assessment and described the process used at St. Luke's, a tertiary care hospital in Bethlehem, Pennsylvania. This second article will describe the resources needed to support a technology assessment program. Technology planning, acquisition, and management will also be discussed. Historically, the health care marketplace has welcomed new technologies. In a future in which providers will be accountable for the outcomes of the care they provide, the ability to evaluate new and existing technologies will be essential for success.

Databases, Factual↗

Catholic healthcare's new crisis: values versus bottom line.

Catholic healthcare faces its second crisis within the last 20 years and must focus on the twin challenges of survival without compromise and fidelity to Christian values to deal with it. The first crisis occurred from 1965 to 1975, when 150 Catholic hospitals closed or surrendered their identity because of fewer religious men and women to staff them and stricter government regulations. Since then Catholic healthcare has undergone renewal and rebirth: Religious institutes view the healing work as being responsive to the Church's contemporary needs, recruit staff and personnel who embrace the Gospel values, and emphasize the belief that social justice issues are at the heart of the Gospel message. The current crisis is the conflict between Christian values and a healthy bottom line. The fiscal solvency of healthcare facilities is threatened by a downturn in utilization, increased competition, reduced reimbursement, dwindling philanthropic support, and skyrocketing costs of medical services and technology. The challenge is to remain fiscally viable without compromising integrity. Several responses are possible, including broad participation by the laity and interinstitutional collaboration.

Catholicism↗

Written progress report materials: blood usage review.

The following article is the third in a series of articles specifying the types of documentation and evidence organizations should include in the written progress reports (WPRs) they submit to clear contingencies. Since it is difficult to anticipate all conditions that may result in contingencies, the guidelines presented here address the most common response areas for organizations. Contingencies directed to more specific problems may require a more precise response than these guidelines set forth.

Accreditation↗

Managing stakeholder loyalty.

The authors question the utility of relying on the conventional wisdom in healthcare that satisfaction is the proper measure of strategic health. They offer four reasons why "stakeholder value" is the more appropriate measure. They present a case of a large midwestern HMO that has evolved to a stakeholder value approach. They demonstrate the linkages among the different components of the Stakeholder Value Information System, how stakeholder assessments of value drive loyalty and other key measures, and how that system can be used to inform strategic and operational decision making.

Attitude of Health Personnel↗

Therapeutic facet joint interventions in chronic spinal pain: a systematic review of effectiveness and complications.

BACKGROUND: Facet joint interventions are used frequently for managing chronic spinal pain. Evidence continues to accumulate supporting the clinical effectiveness of these procedures and defining potential complications. OBJECTIVE: To evaluate the effectiveness of three types of facet joint interventions (facet joint injections, medial branch blocks and facet joint neurotomy) in managing spinal pain. STUDY DESIGN: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and Cochrane Musculoskeletal Review Group for randomized trials. METHODS: Data sources included relevant literature of the English language identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years. Analyses were performed for the different modes of facet joint interventions of cervical, thoracic and lumbar spine, to determine short- and long-term outcome measurements and complications associated with the procedures. OUTCOME MEASURES: The primary outcome measure was pain relief. For facet joint injections and medial branch blocks, short-term pain relief was defined as relief less than 6 weeks, and long-term as 6 weeks or longer. For medial branch radiofrequency neurotomy, short-term relief was defined as pain relief of less than 3 months, and long-term as 3 months or longer. Other outcome measures included functional improvement, improvement of psychological status, and return to work. RESULTS: For lumbar intraarticular facet joint injections, there was moderate evidence for short-term improvement, and limited evidence for long-term improvement. The evidence was negative for cervical intraarticular facet joint injections. For cervical and lumbar medial branch blocks with local anesthetics and steroids, the evidence was moderate. The evidence for pain relief with radiofrequency neurotomy of medial branch nerves was moderate to strong. CONCLUSION: The evidence for facet joint interventions ranged from negative to strong.

Journal Article↗

Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications.

BACKGROUND: Epidural steroid injections are commonly used for chronic spinal pain. However, there is no conclusive evidence regarding their effectiveness, and debate continues as to their value in managing chronic spinal pain. OBJECTIVE: To evaluate various types of epidural injections (interlaminar, transforaminal, and caudal) for managing chronic spinal pain (axial and radicular). STUDY DESIGN: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of the Cochrane Musculoskeletal Review Group for randomized trials. METHODS: Data sources included relevant English literature identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed for trials with different control groups, with different modes of epidurals (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). OUTCOME MEASURES: The primary outcome measure was pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement was defined as less than 6 weeks, and long-term improvement was defined as 6 weeks or longer. RESULTS: For lumbar radicular pain with interlaminar lumbar epidural steroid injections, the level of evidence was strong for short-term relief and limited for long-term relief. For cervical radicular pain with cervical interlaminar epidural steroid injections, the evidence was moderate. The evidence for lumbar transforaminal epidural steroid injections for lumbar nerve root pain was strong for short-term and moderate for long term improvement. The evidence for cervical transforaminal epidural steroid injections for cervical nerve root pain was moderate. The evidence was limited for lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief. For managing chronic postlumbar laminectomy syndrome and spinal stenosis the evidence was limited for low back and radicular pain. The evidence was moderate for chronic low back pain. CONCLUSION: The evidence for effectiveness of epidural injections in managing chronic spinal pain ranged from limited to strong.

Journal Article↗

Are diagnostic lumbar medial branch blocks valid? Results of 2-year follow-up.

The precise cause of low back pain based on clinical history, physical examination, radiological imaging, and electrophysiological testing can be identified in only 15% of patients in the absence of disc herniation and neurological deficit. The prevalence of chronic lumbar zygapophysial (facet) joint pain ranges from 15% to 45% utilizing comparative local anesthetic blocks in controlled settings in accordance with the criteria established by the International Association for the Study of Pain. Currently, facet joint injection procedures are considered as the gold standard in the diagnosis of facet joint pain. Facet blocks have been criticized as lacking diagnostic validity, along with other tests, including discography, neurophysiologic tests, stress radiographs, x-ray studies, bone scintigraphy, thermography and diagnostic ultrasound. However, these assumptions have been based on biased evaluations without consideration of the criteria of the International Association for the Study of Pain, as well as the nature of controlled diagnostic blocks. Utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for Systems to Rate the Strength of Scientific Evidence, it was shown that the validity, specificity, and sensitivity of facet joint nerve blocks are considered strong in the diagnosis of facet joint pain. The accuracy of a diagnostic test is best determined by comparing it to an appropriate reference standard, such as biopsy, surgery, autopsy or long-term follow-up. Since we are unable to apply reference standards of biopsy, surgery, or autopsy, and pain relief has been argued as an inconsistent feature, long-term follow-up has been considered as the best indicator. This study was undertaken to evaluate stability of the diagnosis of lumbar facet joint pain following comparative local anesthetic blocks at a follow-up after 2 years. The results showed that 85% of the patients available for follow-up withstood the diagnosis of facet joint pain at the end of 2 years, whereas this proportion decreased to 75%, if all the patients in the study were included in the analysis.

Journal Article↗