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[Accelerating consult letter time in inpatient psychiatric and psychotherapeutic care].

Consult letters are the main way of relaying information between attending physicians involved in patient treatment at different levels of care and should therefore reach continuing care physicians with minimal delay. The quality assurance project described here was intended to reduce dispatch times for inpatient consult letters at our department of psychiatry and psychotherapy. To accomplish this, different measures were put to work at two levels of intervention. These included standardizing work flow, centralizing and optimizing work distribution in the secretaries' office, enabling faster access to typewritten consult letters by way of central data storage on the clinic's server, sending email notifications to all persons involved, using a central office for signing letters, and prompt monitoring and reporting of consult letter delays. These interventions helped reduce the average delay of dispatching consult letters from 29 days to 11. All in all, the project led to a high degree of workplace satisfaction for all persons involved and should be adaptable to other departments and units without difficulty. In our own department, ward-specific consult letter efficiency has become an important quality indicator.

Delivery of Health Care↗

Influence of delayed staging laparotomy after laparoscopic removal of ovarian masses later found malignant.

OBJECTIVE: To determine whether delayed laparotomy after attempted laparoscopic excision of an ovarian mass later found to be malignant has an impact on the stage of disease. METHODS: A questionnaire regarding laparoscopic management of ovarian masses later found to be malignant was mailed to all gynecologic departments in Austria. Of the 70 cases reported, laparotomy was performed after laparoscopy in 48 cases. In 24 of these cases, laparotomy was performed within 17 days of laparoscopy, whereas 24 cases involved a delay of more than 17 days. Twenty-two patients in whom laparotomy was performed immediately after laparoscopy were used as controls. RESULTS: In patients with borderline tumors who underwent laparotomy more than 17 days after laparoscopy, the odds ratio (OR) for International Federation of Gynecology and Obstetrics (FIGO) stage IIB-IV disease was 5.3 (95% confidence interval [CI] 0.40, infinity), compared with patients undergoing immediate laparotomy (multivariate analysis). Patients with invasive ovarian cancer who underwent laparotomy more than 17 days after laparoscopy had an OR of 9.2 (CI 0.92, 481) for stage IIB-IV disease compared with patients undergoing immediate laparotomy (multivariate analysis). In patients with borderline tumors, multivariate analysis showed that the timing of laparotomy is an independent prognostic factor for the stage of disease. In invasive ovarian cancer, none of the factors evaluated by multivariate analysis was found to be an independent prognostic factor for the distribution of disease stage. A delay between laparoscopy and laparotomy may affect adversely the distribution of disease stage. CONCLUSION: The timing of subsequent laparotomy was found to be a factor predictive of the distribution of disease stage.

Adolescent↗

Fatigue in polio survivors.

OBJECTIVES: Fatigue is commonly reported among polio survivors. The aims of the present study were to examine the incidence of perceived fatigue among a sample of Norwegian polio survivors, and to examine the association between the level of fatigue and sociodemographic and health variables. MATERIALS AND METHODS: A mailed questionnaire containing, among others, Fatigue Questionnaire, Fatigue Severity Scale, sociodemographic and health variables were sent to a representative group of 312 Norwegian polio survivors. 276 subjects (88%) answered the questionnaire. RESULTS: The incidence of fatigue among the polio survivors were considerably higher than in the normative data. Physical fatigue, more than mental fatigue, represented the major problems. Polio subjects who reported severe fatigue had significantly more other diseases and health problems than the normative group. CONCLUSIONS: The diagnosis and treatment of other or related physical conditions should be given higher priority in the management of persons with late effects of poliomyelitis, as these conditions probably can be the reasons for fatigue more than poliomyelitis sequelae alone.

Adolescent↗

Genetic and environmental factors in complex diseases: the older Finnish Twin Cohort.

In studies on the Finnish Twin Cohort, we investigate genetic and environmental determinants of common, complex diseases, and their behavioral risk factors in Finland, a genetically unique and culturally homogenous population. We have formed the following databases: 1) Like-sexed twin pairs (13,888 pairs of known zygosity) form the older Twin Cohort. They have participated since 1975 in mail surveys, in clinical examinations for subsamples, and have been followed-up for morbidity using national medical registers; 2) The older Twin Cohort was expanded in 1996 to include opposite-sex pairs born 1938-1957 (c. 8000 pairs); 3) Two, new longitudinal studies of adolescent twins and their families, form a complementary, ongoing study base described in more detail in an accompanying article. Genetic and environmental effects vary over the life-span, and only longitudinal studies in genetically informative data sets permits the evaluation of such effects. Finally, the inclusion of DNA-based genetic information in a phenotypically rich family data base will offer a unique resource for research in genetic epidemiology and behavioral medicine.

Adolescent↗

Adherence to Drug-Dispensation and Drug-Administration Laws and Guidelines in Collegiate Athletic Training Rooms.

OBJECTIVE: To assess adherence in collegiate athletic training rooms to federal drug laws and to describe current practices. DESIGN AND SETTING: We created a survey of drug-law adherence using federal drug laws and administration guidelines and mailed it to randomly selected certified athletic trainers (ATCs) in United States college and university athletic training rooms. Means, standard deviations, and cross-tabulations were calculated to assess demographic information. A nonparametric test (Kruskal-Wallis) was calculated to compare adherence-score means. RESULTS: Adherence scores were collected from 168 college and university ATCs. The data suggest that ATCs in most athletic training rooms are still not complying with federal drug laws. Drug-dispensation and -administration adherence scores ranged from 5 to 20 (20% to 80% adherence) of 25 points. On average, 49.3% of ATCs in athletic training rooms had marginal adherence to federal regulations (12.34 adherence score). The difference between adherence scores and National Collegiate Athletic Association athletic divisions (Division I, II, III, and III/National Association of Intercollegiate Athletics; P <.002) was significant. In most athletic training rooms, ATCs (55.9%) and students (13.3%) dispensed prescription drugs. In addition, ATCs in most athletic training rooms (53.8%) administered any amount of over-the-counter medication as necessary, and many did not record the transaction (46.2%). DISCUSSION: Nine years after the National Collegiate Athletic Association drug-distribution study in university athletic programs, similar problem areas persist, including unqualified personnel dispensing medications, inappropriately packaged and labeled medications, and a lack of record keeping. CONCLUSIONS: Athletic trainers should work in conjunction with members of the sports medicine team to review federal and state laws and revise institutional drug policies and procedures to comply with regulations in order to provide the best health care to student athletes in a legal and safe manner.

Journal Article↗

Use of HFE mutation analysis for hereditary hemochromatosis: the need for physician education in the translation of basic science to clinical practice.

BACKGROUND: Hereditary hemochromatosis (HH) is a common hereditary disorder of iron metabolism causing iron overload, organ failure, and malignancy. Preclinical diagnosis using HFE gene analysis followed by prophylactic phlebotomy can completely prevent the disease. METHODS: We conducted a mail survey of all registered primary care physicians, gastroenterologists, and hematologists in Arkansas (n = 860) to determine utilization of HFE mutation analysis in clinical medicine a year after the new molecular test first became available. RESULTS: Of 346 responding physicians (40%), 71 (21%) were aware of the test, 36 (10%) knew that the test was available in Arkansas, and 10 (3%) had used the test. One physician had used the test to screen first-degree relatives of a homozygous HH proband. CONCLUSIONS: Because of poor utilization of the test, the discovery of the role of HFE mutations in HH has had minimal impact on clinical care in Arkansas.

Arkansas↗

Changes in management of diabetic retinopathy by Australian ophthalmologists as a result of the NHMRC clinical guidelines.

PURPOSE: To document changes in management of diabetic retinopathy by Australian ophthalmologists after release of the National Health and Medical Research Council (NHMRC) clinical guidelines. METHODS: Self-administered questionnaires were mailed to Australian ophthalmologists prior to release of the NHMRC guidelines for the management of diabetic retinopathy, and at one and 2.5 years after release of the guidelines. The questionnaires elicited information about current management practices in relation to diabetic retinopathy RESULTS: The response rate for the baseline and two follow-up surveys was 82%, 81%, and 80%, respectively. More than 85% of the ophthalmologists responded that the guidelines were useful in improving management, were easy to understand, and were already part of their routine clinical practice. A relatively small percentage (12%) felt that the guidelines made recommendations that were not practical or feasible. Contrary to the NHMRC guidelines, at the second follow-up survey, only 50% of the ophthalmologists said that they would almost never perform fluorescein angiography in eyes with mild non-proliferative diabetic retinopathy. The change from baseline to the second follow-up in the percentage of ophthalmologists who would perform cataract surgery after treating clinically significant macular oedema (as advised by the NHMRC guidelines) was statistically significant (baseline = 83.7%, 95% confidence limit = 80.4, 87.0; second follow up = 90.4, 95% confidence limit = 87.3, 93.5). CONCLUSIONS: Distribution of the printed NHMRC Clinical Practice Guidelines: Management of Diabetic Retinopathy and full colour Retinopathy Chart resulted in a significant change in the recommended order of treatment of clinically significant macular oedema. However no significant change in the use of fluorescein angiography was documented.

Australia↗

The Blue Book oral health program: a collaborative partnership with statewide implications.

ISSUE ADDRESSED: Basic oral health knowledge and skills are essential for parents and child health professionals to promote good oral health and the prevention of dental disease in young children. The aim of the Blue Book Program was to provide accurate and appropriate oral health information to all parents of newborn babies and young children in New South Wales (NSW), Australia, and child health professionals to address the serious issue of early childhood caries (ECC) and to increase general health involvement in oral health promotion. METHODS: Oral health information sheets were developed based on a review of current literature plus input from paediatric dental specialists. Information was pre-tested with child and family health nurses and their clients. Two hundred and forty child health professionals, predominately child and family health nurses, attended in-service education in early childhood oral health in 2004. Following this, a trial run of 40,000 oral health information sheets were printed and distributed to participating nurses. RESULTS: The NSW Department of Health approved the request for inclusion of oral health information in the Blue Book for the 2006 print run. A precondition for re-inclusion was the development of oral health guidelines for child health professionals. The Centre for Oral Health Strategy NSW has begun work on these guidelines and has incorporated this strategy into a new and comprehensive plan for a statewide Early Childhood Oral Health Program. CONCLUSION: The methods used in this program support a collaborative partnership approach between oral health professionals, health promotion experts, child and family health nurses and NSW regulatory bodies. This approach is essential to address the serious issue of early childhood caries.

Age Factors↗

Anthropometric characteristics and risk of multiple myeloma.

BACKGROUND: Few studies have examined obesity and risk for multiple myeloma, and the results are inconsistent. Laboratory evidence suggests mechanisms through which obesity could influence carcinogenesis of this hematopoietic malignancy. METHODS: We examined the association between anthropometric characteristics and incident multiple myeloma in a prospective, population-based sample of 37,083 postmenopausal women. In 1986, the women completed a mailed questionnaire that included self-report of height and weight, and friend measurement of waist and hip circumferences. During 16 years of follow up, 95 cases of multiple myeloma were identified through linkage to the Iowa Cancer Registry. RESULTS: In an age-adjusted model, women in the highest category of several anthropometric measurements compared with the lowest category were at increased risk of developing multiple myeloma. For body mass index (kg/m), the rate ratio (95% confidence interval) was 1.5 (0.92-2.6); for weight, 1.9 (1.1-3.4); for waist circumference, 2.0 (1.1-3.5); and for hip circumference, 1.8 (1.0-3.0). CONCLUSION: Greater adiposity may increase the risk of multiple myeloma.

Aged↗

The composition of old age homes in South Africa in relation to the residents and nursing personnel.

This research project is the first phase of a larger study aimed at describing and exploring the cost-effective utilisation of nursing personnel in old age homes in South Africa. The aim in the first phase was to describe the composition of the residents and nursing personnel of old age homes in South Africa. An exploratory and descriptive survey was conducted and the data was collected by means of a questionnaire. The questionnaire also included data on the financial implications of utilising professional nursing personnel to manage the care of the frail residents/older persons in old age homes in South Africa. The questionnaires were mailed to 612 old age homes published in the Hospital and Nursing Yearbook of 1997 (100% sample). A total of 145 (23.69%) questionnaires were returned and included in the descriptive data analysis. The residents are mainly female (77%), older than 85 years of age, belong to the white race group (83.74%) and are highly dependent on nursing care and supervision (69.7%). Old age homes are mainly managed/controlled by welfare organisations and lay health care workers are utilised to a large extent (42.22% of the nursing workforce) to render nursing care to the frail residents. The cost-effective utilisation of nursing personnel (registered and enrolled), as well as the utilisation of lay health workers in old age homes, needs to be critically examined.

Age Distribution↗

Foot-care awareness. A survey of persons aged 65 years and older.

The authors conducted a mail survey that examined foot problems, rates of utilization of foot-health services, and the perception of foot problems as medical conditions in a sample of people aged 65 years and older who lived independently. Although 71% of the 128 respondents reported suffering from foot problems, only 39% had consulted medical personnel about their feet, and only 26% identified their foot pathologies as medical conditions. More female than male respondents experienced foot problems and had visited medical personnel about their feet. Increased education of older individuals about their foot-care requirements, as well as increased access to podiatric medical services, is recommended.

Aged↗

State gun control advocacy tactics and resources.

CONTEXT: Enacting state laws to regulate firearm use, availability, or manufacture is one plausible strategy for preventing firearm-related injuries. Organizations that use a wide range of advocacy tactics may be successful in promoting gun control policies. OBJECTIVES: To describe tactics commonly used by groups that advocate for state gun control laws and to assess whether financial resources were associated with groups' use of these advocacy tactics. DESIGN/PARTICIPANTS: We identified 679 local and state organizations potentially active on state-level gun control issues in 1998 and mailed a 153-item questionnaire to the groups' leaders. MAIN OUTCOMES: Organizations' use of 35 gun control advocacy tactics. RESULTS: Seventy-nine percent (n=538) of groups responded to our survey, and, of those eligible, eighty-one percent (n=207) completed questionnaires. Organizations commonly used public education, media, and legislative lobbying tactics, and fewer engaged in electioneering and litigation. Except for lobbying, no associations were found between groups' use of advocacy tactics and their level of financial resources. CONCLUSIONS: Organizations advocating for state gun control laws have a varied tactical repertoire, with fewer using electioneering and litigation than other approaches. Financial resources do not appear to be the determining factor in the advocacy methods employed.

Chi-Square Distribution↗

Changes in smoking prevalence among Finnish physicians 1990-2001.

BACKGROUND: The aim of the study was to investigate the changes in smoking habits among physicians in Finland between 1990 and 2001. METHODS: Three independent cross-sectional surveys using a self-administered questionnaire regarding smoking behaviour as well as knowledge, skills and attitudes in smoking were carried out by mail among physicians in Finland in 1990, 1995 and 2001. RESULTS: The prevalence of daily smoking decreased in both men and women between 1990 and 1995, but did not decrease any further between 1995 and 2001. In 2001, 7% of male and 4% of female physicians reported smoking daily. Daily smoking was highest (8-12%) among male physicians in the oldest age group. Occasional smoking was more prevalent at a younger age (22-24% in males and 7-10% in females). CONCLUSION: Smoking prevalence among physicians in Finland is relatively low and has not changed since 1995. A further reduction in daily and occasional smoking requires a different, specially adjusted and physician-targeted approach.

Adult↗

Impact of physicians' perceptions of malpractice and adaptive changes on intention to cease obstetrical practice.

Physicians who provide obstetrical care in rural areas face exposure to liability action and confront a critical decision--whether to continue to offer these services. This paper draws upon social-psychological and decision theories to investigate this decision. Ninety-four percent of all obstetricians and family and general physicians practicing in the 12 nonmetropolitan counties of one state responded to a mail survey that asked about their intention to continue or discontinue obstetrical practice, two dimensions of subjective risk (perceived likelihood of threats in the malpractice environment and perceived magnitude of negative consequences from being sued), and adaptive changes to protect against malpractice. The results suggest that (a) perceived extent of negative consequences (but not perceived likelihood of malpractice threats) drives intention to leave obstetrics, (b) the professional and reputational impacts of a suit--not the dollar amount of award or settlement--predicts intention to stop practicing obstetrics, and (c) physicians planning to continue providing obstetrical care in the future have made recent practice changes that may further exacerbate access problems.

Adult↗

Tube feeding in advanced dementia: an exploratory survey of physician knowledge.

The administration of artificial nutrition by means of a percutaneous endoscopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia is commonplace, yet the treatment is associated with significant treatment burdens and unclear benefits in this population. In addition, there is wide and unexplained geographic variability in the use of PEG in advanced dementia, which may stem partly from physicians' lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess physician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other physician characteristics are associated with physician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non-evidence based, indications for tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritional parameters, preventing an uncomfortable death, and others. Discrepancies between physician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education ofprimary care physicians in order to ultimately provide better end-of-life care for patients with advanced dementia.

Chi-Square Distribution↗

Examination services provided by dental hygienists.

The information presented in this paper was obtained as part of an ongoing longitudinal study of 1982 dental hygiene graduates. This paper presents information contracted by the American Dental Hygienists' Association and includes information on examination services provided to new and recall, child and adult dental hygiene patients by dental hygienists. Mail questionnaires were sent to a cohort of 1,008 dental hygienists who graduated in 1982. Data presented here were collected in September 1986. Surveys were returned from 766 subjects, 77% of those with valid addresses. Of the respondents, 455 were working in traditional clinical dental hygiene positions and provided information on patient examination services. The frequencies reported for the 15 examination services investigated by the dental hygienists varied for child and adult patients and for new and recall patients. Visual gingival examination was the most frequently provided service. In conclusion, dental hygienists need to incorporate additional patient examination services into their diagnostic workups to ensure adequate patient care and to provide adequate information to evaluate their dental hygiene care.

Adult↗

The audition elective and its relation to success in the National Resident Matching Program.

BACKGROUND: Many medical students take audition electives in an effort to improve their chances of being selected by a residency program. PURPOSE: The study was to determine if audition electives improved student success in the National Resident Matching Program. METHOD: A questionnaire was mailed to graduates of the University of South Dakota School of Medicine from 1977 (the charter graduating class) through 1997. Comparisons were done between students who took audition electives and those who did not. Statistical analysis was performed by chi-square or Fisher Exact tests for smaller groups. RESULTS: The data show no statistically significant difference in first-choice matching for the total group (p = .35), primary care (p = .44), or nonprimary care subgroups (p = .38). Sample size is inadequate for sufficient analysis of individual specialties. CONCLUSIONS: The limited time available to provide students with a broad education and the disadvantages of taking audition electives should be considered when advising students about 4th-year schedules.

Chi-Square Distribution↗

Development of a scale to measure gender-role attitudes toward breast-feeding among primiparas.

Women's roles have undergone rapid transformation in recent decades and appear to affect the decision to breast-feed. Research in this area has been hampered by the lack of valid instruments to measure the relevant domains of gender-role related considerations. This study developed a scale to measure gender-role attitudes toward breast-feeding in primiparous women. Ninety-one married women, recruited during childbirth education classes in the Chicago metropolitan area, were surveyed by mail at eight weeks postpartum regarding their experiences as new mothers. Questionnaire items measuring infant feeding method (breast-feeding, bottle feeding) and attitudes toward breast-feeding were developed specifically for this investigation. Validity and reliability were assessed by structural equations analysis using LISREL. The LISREL fit statistics supported a one factor measurement model and combining the six items into a scale. Reliability analysis yielded a standardized alpha coefficient of .74. If results of future research are promising, the scale could be used to target new mothers with multiple roles for education and support and to evaluate interventions designed to promote positive breast-feeding attitudes and behavior.

Adult↗