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PubMed1996

High-consulting children indicate illness-prone families. A study of 38 rural and 38 urban Swedish children's health and use of medical care.

OBJECTIVE: To study health problems and use of medical care in a group of rural and urban children. To relate a number of socio-demographic factors to the children's consultation frequency. To compare high- and low-consulting children with respect to socio-economic status of the family and use of medical care and sicklisting pattern of their parents. DESIGN: Health check-up at school start. Investigation of the children's medical records from birth to the age of seven, and of their parents' use of primary medical care during the same period. SETTING: Lammhult, a rural community with 3000 inhabitants, and Teleborg, an urban district with 9000 inhabitants, situated in Växjö town, southern Sweden. SUBJECTS: 38 rural and 38 urban preschool children, as well as their parents. MAIN OUTCOME MEASURES: Medical visits encountered and antibiotic courses prescribed during the first seven years of life. RESULTS: Parents having manual occupations and mother being a smoker were factors of importance for the children's use of health and medical care (i.e. gave a high number of medical visits). The 14 high consulters had recurring respiratory tract infections and allergic/asthmatic complaints. Their parents were also high users of primary medical care and they were more often sick-listed than parents of low-consulting children. Rural and urban children made the same number of medical visits and received the same number of antibiotic courses during their first seven years of life. CONCLUSION: With respect to the children's use of health and medical care, we found only minor differences between rural and urban children, whereas socio-economic characteristics of the families were of importance. Moreover, high-consulting children had parents who were high users of primary medical care and who were often sick-listed.

Anti-Bacterial Agents↗
PubMed1990

Factors influencing consultation for management of hearing disability.

The aim of this study was to compare individuals referred to an Audiology Clinic (consulters) with hearing-impaired individuals in the population who have never sought advice (non-consulters) in order to identify factors which lead some individuals with hearing problems to seek management while others with apparently similar impairments do not seek advice. Two hundred and sixty nine consulters referred to the Audiology Clinic at Glasgow Royal Infirmary were compared with 289 individuals identified in the MRC National Study of Hearing who had never sought advice as an adult about hearing problems. Age, sex, socio-economic group and better-ear hearing threshold were controlled for in all analyses. Consulters were found to have more asymmetrical hearing than non-consulters. They had greater measured disability and reported more disability when their measured disability and impairment were controlled for. They were also more handicapped when impairment and disability were controlled for.

Adult↗
PubMed2006

Integration between general practice and mental health services in Italy: guidelines for consultation-liaison services implementation.

PURPOSE: This paper illustrates some guidelines for the implementation of Consultation-liaison services in contexts where GPs work alone. We present some activity data of our experience in the period 1999-2004 and a critical evaluation of what works and what does not work. CONTEXT: In Italy single-sited spontaneous initiatives of co-operation and integration between general practice and psychiatry have been implemented in many regions. Recently, the Italian Health Care Government has begun to encourage integration between primary and secondary care for the management of mental health. The Bologna Consultation-liaison Service opened in 1999 in one area. The service was first located in the Community Mental Health Centre and subsequently in a medical non-psychiatric outpatient service. In 2002, the services were implemented in the overall city area, and the Bologna Consultation-liaison Service had its own office in the centre of the town. DATA SOURCE: Data have been collected by reviewing clinical charts. They include clinical (mental status examination, progress notes) and socio-demographic data, assessment scales that measure psychological distress and disability, reports for GPs, and consultation outcome. CONCLUSION: A consultation-liaison service like the one proposed in this paper could contribute to an efficient and fully-integrated collaborative management of common psychiatric disorders, reducing the use of mental health services.

Journal Article↗
PubMed1990

Analysis of videotaped consultations to certify competence.

The assessment of videotaped genuine consultations in order to provide feedback to the learner is now a well accepted part of postgraduate training for general practice. This article reports on a pilot study which investigates the adaptation of videotape assessment of genuine patient consultations as an alternative to the present simulated patient interview segments of the examination for Fellowship of the Royal Australian College of General Practitioners. In particular, the study addresses: the feasibility and cost of collecting and assessing a suitable range of videotaped consultations using portable videocamera equipment and remote examiners; the interobserver reliability of four independent examiners; and the correlation between scores on two different rating scales. The results demonstrate that the assessment of videotaped genuine consultations has the potential to become a means of end-point assessment of clinical competence. The problem of how to collect videotapes of a suitable range and number of consultations to permit a candidate to demonstrate proficiency needs to be addressed and will be followed up in a trial of the method during 1990.

Australia↗
PubMed1998

Why do dyspeptic patients over the age of 50 consult their general practitioner? A qualitative investigation of health beliefs relating to dyspepsia.

BACKGROUND: The prognosis of late-diagnosed gastric cancer is poor, yet less than half of dyspeptic patients consult their general practitioner (GP). AIM: To construct an explanatory model of the decision to consult with dyspepsia in older patients. METHOD: A total of 75 patients over the age of 50 years who had consulted with dyspepsia at one of two inner city general practices were invited to an in-depth interview. The interviews were taped, transcribed, and analysed using the computer software NUD.IST, according to the principles of grounded theory. RESULTS: Altogether, 31 interviews were conducted. The perceived threat of cancer and the need for reassurance were key influences on the decision to consult. Cues such as a change in symptoms were important in prompting a re-evaluation of the likely cause. Personal vulnerability to serious illness was often mentioned in the context of family or friends' experience, but tempered by an individual's life expectations. CONCLUSION: Most patients who had delayed consultation put their symptoms down to 'old age' or 'spicy food'. However, a significant minority were fatalistic, suspecting the worst but fearing medical interventions.

Aged↗
PubMed1981

Evaluation of a computerized digoxin pharmacokinetic consultation service.

A pharmacy-conducted digoxin pharmacokinetic consultation service was implemented to determine the influence of the service on patient serum digoxin concentrations. Changes in digoxin dosages and serum levels during a three-week period were compared with a three-week control period in which the consultation was not offered. Of 47 patients evaluated, there was no statistically significant (P > 0.05) difference between the control and the study group in terms of population variables. The study group receiving pharmacokinetic consultations showed a significantly greater (P > 0.05) number of dosage changes resulting in therapeutic serum drug levels than did the control group whose physicians received a report of serum drug level by itself. The number of patients with steady-state serum digoxin levels in the therapeutic range of 1-2 ng/ml increased from 45.5% to 80% as a result of the clinical pharmacokinetic consultations. This study demonstrated that a pharmacy-based clinical pharmacokinetic consultation service can provide potential benefits to the patient by aiding clinicians in optimizing serum drug concentrations.

Computers↗
PubMed1999

[Economical evaluation for drug consultation at home].

We started drug consultation at patients' homes in October, 1998. The number of drug consultations are 2.65 per month per patient and the consulting time is 2.25 hours per patient. The fee for drug consultation is 550 points twice a month. We evaluate the fee for drug consultation. Our data suggest that this fee needs to be 550 points three times a month.

Aged↗
PubMed2001

Practice size: impact on consultation length, workload, and patient assessment of care.

BACKGROUND: Variations in practice list size are known to be associated with changes in a number of markers of primary care. Few studies have addressed the issue of how single-handed and smaller practices compare with larger group practices and what might be the optimal size of a general practice. AIM: To examine variations in markers of the nature of the care being provided by practices of various size. DESIGN OF STUDY: Practice profile questionnaire survey. SETTING: A randomised sample of general practitioners (GPs) and practices from two inner-London areas, stratified according to practice size and patients attending the practice over a two-week period. METHOD: Average consultation length was calculated over 200 consecutive consultations. A patient survey using the General Practice Assessment Survey instrument was undertaken in each practice. A practice workload survey was carried out over a two-week period. These outcome measures were examined in relation to five measures of practice size based on total list size and the number of doctors providing care. RESULTS: Out of 202 pratices approached, 54 provided analysable datasets. The patient survey response rate was 7247/11,000 (66%). Smaller practices had shorter average consultation lengths and reduced practice performance scores compared with larger practices. The number of patients corrected for the number of doctors providing care was an important predictor of consultation length in group practices. Responders from smaller practices reported improved accessibility of care and receptionist performance, better continuity of care compared with larger practices, and no disadvantage in relation to 10 other dimensions of care. Practices with smaller numbers of patients per doctor had longer average consultation lengths than those with larger numbers of patients per doctor. CONCLUSION: Defining the optimal size of practice is a complex decision in which the views of doctors, patients, and health service managers may be at variance. Some markers of practice performance are related to the total number of patients cared for, but the practice size corrected for the number of available doctors gives a different perspective on the issue. An oversimplistic approach that fails to account for the views of patients as well as health professionals is likely to be disadvantageous to service planning.

Family Practice↗
PubMed2001

[Evaluation of three testing strategies for detection of hepatitis C in a hospital medical consultation and in an HIV testing center].

AIMS: Testing for hepatitis C virus (HCV) is recommended. The purpose of this study was to evaluate the efficacy of HCV testing in a medical consultation without an appointment and in an HIV testing center based on three testing strategies: 1997 French Consensus Conference, "Lettre de la Direction Générale de la Santé" (January 1996), and extension to other risk factors. PATIENTS AND METHODS: For 6 months a free blood test was offered to any patient with a risk factor according to the literature. RESULTS: There were 1 736 new patients at the medical consultation and 1 616 at the testing center. The patients were younger at the testing center than at the medical consultation (31.1 vs 43.3 years; P<0.001). Acceptance of screening was better at the testing center (97.8% vs 75.2%; P<0.001). There were more patients exposed to one of the risk factors at the testing center (31.2% vs 13.9%; P<0.001). Tests were more efficient at the testing center: 30 HCV positive patients/1 616 (1.86%) vs 11/1 736 (0.63%, P<0.01). Tests based on the 1997 French Consensus Conference provided detection in 27/30 (90%) of HCV positive patients at the testing center but only 4/11 (36.3%) at the medical consultation (P<0.01). CONCLUSION: Testing was effective in both places but was more efficient at the testing center. Efficacy of the testing strategies differs significantly according to the place of screening. At the testing center, screening can be restricted to patients with a history of intravenous drug use and blood transfusion. At the medical consultation, screening should be extended to other risk factors.

Adult↗
PubMedDate not supplied

[Amnesic presentations of the compulsive obsessional confusions (about 3 patients appearing in a consultation of memory)].

Disorders or complaints of memory are a frequent cause of consultation in depression, major anxiety and psychiatry disease with personality disorders. We report 3 patients with obsessive compulsive disorder (OCD), without diagnosis and treatment, examined in a specialized memory consultation. They always had OCD with cognitive checking. Diagnosis of transient global amnesia and temporal complex seizure were discussed in 2 cases. Psychometric impairment only was observed in first free recall of a verbal memory task and was no specific. Behavioural during testing seemed to be very important to analyse. First, a 49-year-old man consulted because he had stereotyped transient amnesia lasted one minute, 2 or 3 times a week, since 6 months. He was a teacher. Transient amnesia always occurred during lessons. Suddenly he didn't know where he was or what he was speaking about. Episodes lasted one minute. After them, he had no confusion and no difficulty in concentration but intense anxiety. In an another hand, when he was in his car, after lessons, he could forget where he was during some minutes. CT scan and EEG were normal. Neuropsychological tests only objectived impairment in first free recall of Grober and Buschke's words. Patient explained that he could not prevent to check responses. He told us checking obsessive compulsive disorder during since long time ago. We discussed clear differences which existed between seizure and ruminations or preoccupations. Secondly, a 55-year-old woman was afraid of her memory performances. She was medical secretary and had no problem in her work but she would like a memory consultation to reassure herself. She was neither depressed nor anxious. She presented curious production in fluency task. She had to produce as many animals's names as possible: she could say 35 names which was an excellent performance but only in alphabetic order! Neuropsychological tests objectived impairment in her first free recall of Grober and Buschke's words. She tried in her first free recall to remember words in alphabetic order. She explained how she was bound to range everything in alphabetic order! She had a lot of rituals. She thought that she had an obsessive compulsive disorder but never consulted about this. The observation illustrated suspiscions about memory operations which could be observed in patients group with obsessive compulsive disorders. Finally, a 62-year-old man told us that he had presented a transient global amnesia during 4 hours. He had an important appointment and was upset about that. He didn't go to it and wandered in his flat. He always asked the same questions and forgot everything. He had no neurological deficit. He was anxious, sad and cried several times. He perfectly remembered the episod and thought that he had a panic attack! Verbal memory tests only objectived difficulties in his first free recall of Grober and Buschke words as the two others patients. He had a story of obsessive compulsive disorder with checking and rituals. In this observation, we discussed clear differences which existed between panic attacks and global transient amnesia. We analyzed patterns of neuropsychological performances which illustrated clinical features of obsessive compulsive disorder. These three patients impaired in their first free recall of verbal memory task. It is not a specific result. We observed during psychometric evaluation, strategic processing which impaired episodic memory: patients tried to check their performances. Memory complaints only were observed in checking obsessive compulsive disorder. It is a difficulty or a doubt about memory capacities. Difficulties could be due to particular cognitive processes who pertubate normal memory capacities.

Female↗
PubMed2002

The relationship between consultation length, process and outcomes in general practice: a systematic review.

The aim of the study was to examine differences in consultation process and health outcomes between primary care physicians who consult at different rates. A systematic review of observational studies was carried out, restricted to English language journal papers reporting original research or systematic reviews. Qualitative analysis with narrative overview of methodology and key results was undertaken, using MEDLINE (1966 to 1999), EMBASE (1981 to 1999), and the NHS National Research Register. Secondary references from this search were also considered for inclusion. Main outcome measures were objectively measured process or healthcare outcomes. Thirteen papers, describing ten studies, were identified. There were consistent differences in several elements of process and outcome between general practitioners (GPs) who consult at different rates. Although average consultation length may be a marker of other doctor attributes, the evidence suggests that patients seeking help from a doctor who spends more time with them are more likely to have a consultation that includes important elements of care.

Appointments and Schedules↗
PubMed2004

Giving patients an audiotape of their GP consultation: a randomised controlled trial.

BACKGROUND: Providing patients with an audiotape of their medical consultation has been a relatively common practice in oncology clinics for some years. However, broader generalisability of the technique has yet to be examined. AIMS: To investigate the efficacy of providing patients with an audiotape of their consultation in a general practice setting. DESIGN OF STUDY: Randomised controlled trial: 95 experimental participants, 85 controls. SETTING: Routine surgeries run by two general practitioners (GPs) in two different health centres. METHOD: All patients attending GP appointments were eligible for inclusion. Patients were followed up by telephone 7-10 days later. RESULTS: More than half (61%) of the patients who received a tape listened to it. Among listeners, 64% rated the tape useful or very useful; 24% noticed information not heard in the consultation. Half of listeners (46%) said that their understanding of the consultation improved after listening to the tape. Half of the listeners (48%) shared the tape with others, of whom 71% found sharing helpful or very helpful. However, 21% of those who shared the information with others found this unhelpful or very unhelpful, suggesting that patients may need to be briefed on the potential risks of sharing. At follow-up a week later, it emerged that being given a tape had no effect on adherence with GPs' advice, nor on anxiety about conditions. CONCLUSION: Providing patients with an audiotape of their GP consultation was positively rated by many patients. Although there were no detectable clinical effects at follow-up, the technique merits further evaluation in general practice.

Adult↗
PubMed2004

Consultant supported intermediate care--a model for remote and island hospitals.

INTRODUCTION: Providing local consultant-delivered hospital services in remote and island communities in the United Kingdom is increasingly problematic due to difficulties with recruitment and retention of staff, statutory restrictions to hours worked by health professionals and the expectation each clinician must manage an externally defined volume of cases to maintain clinical standards. This article describes a before-and-after evaluation of a novel method of providing consultant support for acute internal medicine to an island grouping off the Scottish coast. Under the scheme, local GPs provided acute medical care of inpatients. A consultant general physician was appointed in a district general hospital on the mainland, approximately 100 miles from the island group, to provide a lead clinician role for inpatient services at the island hospital, visiting the island on a twice-monthly basis, undertaking educational sessions and developing local guidelines and care pathways for the management of individual medical conditions. In addition, two junior doctors were appointed to the island hospital to support inpatient care. METHODS: A prospective recording system for case mix was established with agreed evidence-based protocols, developed as integrated care pathways (ICP), for indicator conditions. General case mix was determined during two 6-month periods, June-November 2001 and June-November 2002, before and after implementation of the new arrangements. Performance against an ICP for management of suspected cardiac chest pain was evaluated in detail, examining the process of management, clinical outcome and economics. Data from the clinical literature were used to estimate the potential health gains from observed changes in clinical practice. RESULTS: Total admissions rose by 25% in the second time period, with particular increases noted for cardiovascular, cerebrovascular disease, and cancer. Total air ambulance transfers between the islands and the mainland within these time periods increased by 31%, from 88 to 115 transfers. Recording specific details from the history and frequency of appropriate blood investigations increased and initial steps in management changed considerably after introduction of the ICP. The number of transfers to the mainland teaching hospital increased from 3/37 (8%) in 2001 to 15/56 (27%) in 2002. Based on an estimated 100 patients per year, of whom 15 would receive thrombolysis, total additional patient costs would be 64,000 pounds sterling. The annual cost of the additional resource input into the medical service was 148,000 pounds sterling. Approximately 16 adverse events would be avoided at a combined cost of 212,000 pounds sterling (148,000 pounds sterling direct costs of intervention + 64,000 pounds sterling additional treatment costs) or 13,250 pounds sterling per event avoided. This is a conservative estimate of benefit as all the direct costs of the intervention have been included. CONCLUSIONS: This study shows that appropriate standards of care can be delivered in the setting described. Costs of care increased, but the level of service provided increased concomitantly, and the health benefits were achieved at costs that compare favourably with other interventions recommended by health technology assessment groups. An estimate of notional costs involved in alternative models for the delivery of hospital medical services in a remote area suggests that costs would be similar for a three-consultant service, the present model, and a triage and transfer system. In the future, the models chosen by remote and island communities and healthcare providers are therefore likely to be determined by viability, sustainability and public acceptability rather than cost. Our study indicates that consultant supported intermediate care is a viable model.

Journal Article↗
PubMedDate not supplied

[Consultation skills training is necessary in medical education. Evaluation by student questionnaire and focus group interviews].

At Lund University Medical School communication skills are taught during both the preclinical and clinical part of the medical programme. As part of the training during the 5th year the students are required to videotape at least one patient consultation at a local primary health care centre. The students then meet in groups of 6-7 participants and a group leader to watch the recorded consultations and discuss them. To evaluate the quality of the consultation skills training and to identify potential weaknesses, we used both a quantitative and a qualitative method. A written questionnaire was distributed to all students and three focus group interviews, two with students and one with group leaders, were performed. The focus groups consisted of 5-6 participants each. The students were overall pleased with the training, and the majority thought that their consultation skills had improved. More commitment from the tutors at the health care centres was needed in order for the students to successfully record a complete consultation. Nearly all students found that the participants cooperated well in the groups, and that the group leader helped to create a positive atmosphere and gave constructive advice.

Clinical Competence↗
PubMed2006

[Expected benefits of a nursing consultation on the compliance of the adolescent renal transplantation patient].

Benefits expected from a nurse consultation on the therapeutic compliance of the student with a kidney transplant The therapeutic non-observance of chronic ill teenagers in general, and of teenagers who had a kidney transplant in particular, is a genuine problem of public health. At the children Hospital of Toulouse, from March 2002 to March 2003, a nurse consultation coupled with the medical consultation, was set up for the follow-up of these teenagers. The object of this research in nurse care was to appraise, at the end of a year's operation, the results of this consultation on the therapeutic observance of these teenagers and its operation within the institution. At the dawn of a deep upheaval for the profession, this study enabled us to valorise the nurse expertise combined with the medical activity for the actual benefit of children. The nurse consultation, in the heart of the news for some time, has remained in the heart of our concern for over half a century.

Adolescent↗
PubMed1991

Consultation length in general practice: a review.

Although there is evidence that consultation length has increased in the UK over the last 20 years, it is still short by international standards, and is blamed in part by both general practitioners and the public for failure to deliver high quality care. Consultation length is determined by both doctor and patient variables and these need to be looked at when interpreting observational studies linking longer consultations to beneficial outcomes. Studies of the same doctors consulting at different rates suggest that while many aspects of a doctor's behaviour do not change, longer consultations may be associated with greater patient satisfaction and increased health education/prevention measures.

Family Practice↗
PubMed1990

[Scheduled consultation in primary care. Analysis of several relevant factors].

We carried out a longitudinal prospective study of 5179 appointments with 1782 patients, which generated 4483 scheduled consultation in a 10-month period, so as to evaluate changes in compliance, duration of visit and month of appointment, depending on the age and sex of the patient and the cause for consultation. There were no sex or age group differences in compliance, but there were differences depending on the cause for consultation (p less than 0.0001). Obesity, dyslipemia and family planning were the groups with the lowest compliance. A time longer than 15 minutes for each visit was spent in a greater number of women than of men (p less than 0.0001). The age group with the longest time interval per visit was the 25-34 years group. There was also a difference depending on the cause for consultation, which was also not randomly distributed throughout the surveyed months (p less than 0.05). It was concluded that the compliance with appointments was directly related with the perceived morbidity, that subprograms of attention to women take a longer time per visit, and that the month of appointment determines the distribution of the causes for consultation.

Adult↗
PubMed1990

General practice consultation patterns before and after intentional overdose: a matched control study.

This study investigated the general practice consultations of 46 patients during the year before and 13 weeks after hospital admission for deliberate self-poisoning. These were compared with data for controls matched for age, sex, family structure and area of residence. The frequency of consultations increased as parasuicide approached but this effect was due to large increases in a few patients. The greatest increase in the number of consultations and an increase in subjects consulting for physical problems occurred four to six months before the event. The seriousness of the attempt assessed by suicidal intent was unrelated to consulting pattern either before or after overdose. The rate of default from appointments was less than for controls, although this was not significantly different. Because of the problems in identifying when intentional self-harm will occur and the common presentation being psychosocial distress rather than mental illness, intervention to prevent parasuicide is likely to prove even more difficult than for suicide.

Adolescent↗