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Panic disorder in primary care: Biopsychosocial differences between recognized and unrecognized patients

GENERAL HOSPITAL PSYCHIATRY 2000年第6期22卷 405-411页

作者： Roy-Byrne, PP Katon, W Cowley, DS Russo, JE Cohen, E Michelson, E Parrot, T Univ Washington Sch Med Dept Psychiat & Behav Sci Seattle WA 98195 USA

Studies suggest that the recognition of depression by primary care physicians (PCPs) is most likely in move symptomatic and impaired patients. As part of a randomized effectiveness study in primary cave patients with panic disorder, we examined the baseline characteristics of study patients who were recruited by waiting room screen procedure (n=69) versus patients who were referred to the study by their PCP (n=41). Patients referred by their physicians had a signifi- cantly high frequency of panic attacks, more intense attacks, and more anticipatory anxiety on the Panic Disorder Severity Scale, while screen-identified patients were more medically ill and had worse physical functioning on the SP36. There were no differences in anxiety sensitivity, phobic avoidance, depression, other SF36 measures, disability, or medical service utilization. In conclusion, differences in referred versus screened patients are mostly specific for panic attack-related symptoms, consistent with the notion that patients with move prominent physical symptoms (i.e., panic attacks) are more often recognized and referred in busy clinical settings. The better medical status and physical functioning of referred patients may indicate greater physician recognition of panic in patients who appear less medically ill. However;the many clinical and functional similarities between these two patient samples suggests that symptomatic primary care patients with panic may not always be identified by their PCPs and argues for the value of population-based screening for panic in primary care. (C) 2000 Elsevier Science Inc.

关键词：家庭医学/方法家庭医学/标准健康状况普查/方法普查/统计学和数值数据精神卫生惊恐病/分类惊恐病/诊断惊恐病/病因学初级卫生保健/方法初级卫生保健/标准精神病状态评定量表转诊和会诊/统计学和数值数据危险因素疾病严重程度指数青少年成年人老年人女(雌)性人类男(雄)性中年人

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Enabling the diagnosis of occult psychiatric illness in the emergency department: A randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system

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ANNALS OF EMERGENCY MEDICINE 2001年第2期37卷 132-140页

作者： Schriger, DL Gibbons, PS Langone, CA Lee, S Altshuler, LL Univ Calif Los Angeles Ctr Emergency Med Los Angeles CA 90024 USA Univ Calif Los Angeles Dept Psychiat Los Angeles CA USA Univ Calif Los Angeles Sch Med Los Angeles CA USA

Study objective: Undiagnosed mental illness is highly prevalent and produces needless morbidity. Emergency department patients with vague or longstanding complaints are at risk far occult mental illness, but are seldom diagnosed. We conducted this study to determine whether a previously validated, self-administered, computerized psychiatric interview (Primary Care Evaluation of Mental Disorders [PRIME-MD]) could increase the detection of occult psychiatric illness in the ED. Methods: This was a randomized, controlled trial of consecutive patients enrolled during convenient times at a university teaching hospital ED with an annual census of 38,000. ED house staff and attending physicians participated. Patients were those with nonspecific complaints potentially associated with occult psychiatric illness (eg, long-standing headache, abdominal or back pain). Exclusion criteria were known psychiatric illness, complaint, or medication;and straightforward reason for the ED visit. Consenting subjects completed the PRIME-MD questionnaire in the waiting room, and were randomly assigned to either the "report" (report results given to physician) or "no-report" groups. PRIME-MD results were clipped to the front of the chart of report group patients. There was no other intervention. The main outcome measures were the percentage of all patients and percentage of patients with a PRIME-MD diagnosis who received a psychiatric diagnosis, consultation, or referral from the emergency physician. Results: A total of 339 (5.1%) of all patients were approached;230 consented to participate in the study, and 218 completed the PRIME-MD session and were randomly assigned to study groups. Ninety-two patients in the report group and 98 cases in the no-report group were analyzed. Patients were omitted for the following reasons: left without being seen (8), mistakenly enrolled (10), or unretrievable medical records (10). Seventy nine (42%) patients received a psychiatric diagnosis from PRIME-MO and

关键词：共病现象诊断计算机辅助/方法诊断计算机辅助/心理学急诊处理/方法急诊处理/心理学急诊处理/统计学和数值数据交谈心理学/方法普查/方法普查/心理学精神障碍/并发症精神障碍/诊断精神障碍/心理学病人接受卫生保健的程度/心理学问卷调查/标准转诊和会诊/统计学和数值数据成年人女(雌)性人类男(雄)性中年人

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Influence of postal distribution of The Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial

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FAMILY PRACTICE 2000年第1期17卷 46-52页

作者： Kerry, S Oakeshott, P Dundas, D Williams, J Univ London St Georges Hosp Sch Med Dept Gen Practice & Primary Care London SW17 0RE England

Background. The Royal College of Radiologists (RCR) have produced regularly updated guidelines on radiological referrals since 1990. A small study in 1992 showed postal distribution of guidelines reduced general practitioners' referrals over the subsequent 9 weeks. However there have been no randomized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care. Objectives. To see if the introduction of radiological guidelines into general practices together with feedback on referral rates reduces the number of GP radiological requests over one year;and to explore GPs' attitudes to the guidelines. Methods. Sixty-nine practices referring patients to St George's Healthcare Trust were randomly allocated to intervention or control groups. In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practices in the intervention group. After 9 months intervention, practices were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months. The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines. Control practices were sent the guidelines at the end of the study. All doctors were sent a questionnaire about the guidelines. Results. A total of 43 778 radiological requests were made during the two years 1994-1996. In practices receiving the guidelines there was a 20% reduction in requests for spinal examinations compared with control practices (P < 0.05). This corresponded to the effect reported by GPs. There was also a 10% difference between the groups in the total number of requests made, but due to wide interpractice variation in referral rates this failed to reach statistical significance. Conclusions. Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one y

关键词：医务工作者的态度置信区间家庭医学/统计学和数值数据反馈随访研究伦敦医师诊疗模式/统计学和数值数据邮政问卷调查放射摄影术/统计学和数值数据放射摄影术胸部/统计学和数值数据放射学转诊和会诊/统计学和数值数据脊柱/放射摄影术人类

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Patterns and appropriateness of referral from general dental practice to specialist oral and maxillofacial surgical services

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BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY 2000年第4期38卷 320-325页

作者： Coulthard, P Koron, R Kazakou, I Macfarlane, TV Univ Manchester Dent Hosp Manchester M15 6FH Lancs England

In this study we investigated patterns of referral and appropriateness of referrals to specialist oral and maxillofacial surgery services, using postal questionnaires and referral letters. The most common reasons for referral were the expected difficulty of the operation, the medical condition of the patient and the lack of facilities for general anaesthesia, Most referrals were made to the oral and maxillofacial surgery department of a general hospital but almost three-quarters of the respondents stated that they would refer patients to specialist surgical dentistry practices in the future. Few referrals to a university department of oral and maxillofacial surgery were considered to be inappropriate, nor were requests for a particular type of anaesthesia. Any future transfer from secondary to primary care for oral surgery may be hindered by the reduction in facilities for general anaesthesia in the primary care setting.

关键词：麻醉牙科/统计学和数值数据临床工作能力牙医诊疗模式/统计学和数值数据英格兰开业医生牙科/统计学和数值数据卫生服务滥用/统计学和数值数据问卷调查转诊和会诊/统计学和数值数据外科口腔/统计学和数值数据成年人女(雌)性人类男(雄)性中年人

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Characteristics of private medical practice in India: a provider perspective

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HEALTH POLICY AND PLANNING 1999年第1期14卷 26-37页

作者： Bhat, R Indian Inst Management Ahmedabad 380015 Gujarat India

Supply factors, depicted by input market conditions and government regulations, and demand factors, depicted by financing mechanisms and utilization patterns, are likely to determine the shape and character of private medical practice. The interaction of this complex set of factors will have considerable implications for the cost, access and quality of services offered by this sector. Understanding these characteristics from a provider perspective is imperative to influence the behaviour of providers in this sector. This paper describes some of the important characteristics of private medical practice using a case study of an urban district in India, Ahmedabad, and analyzes their implications. Using survey data of 130 private doctors in the allopathic system, the paper describes broad characteristics of private medical practice using parameters such as growth of private practice, patient load and referrals within the sector, payment methods and determinants, patient concerns, and risks associated with private practice. The paper presents views on the prevalence of various undesirable practices in the private medical sector. It also discusses the awareness of providers about selected important regulations. The findings suggest that growing capital intensity due to cost of location, medical equipment and technology, and financial sources of capital investments are some unfavourable environmental factors experienced by private providers. The findings also indicate a high prevalence of various undesirable practices and low awareness of the objectives of important legislation among practicing doctors. Lack of awareness of important and relevant legislation raises serious questions about the implementation of these laws. The paper identifies the strong need for instituting and implementing an effective continuing medical education programme for practicing doctors, and linking it with their registration and continuation of their license to practice. The paper also suggests

关键词：问卷调查转诊和会诊/统计学和数值数据偿还途径危险因素

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Cardiac management by pediatricians versus pediatric cardiologists in an inpatient academic center

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AMERICAN HEART JOURNAL 2003年第3期145卷 424-429页

作者： Benun, J Fisher, SD Orav, EJ Schwartz, ML Exil, V Messere, C Lipschultz, SE Univ Rochester Med Ctr Div Pediat Cardiol Rochester NY 14642 USA Boston Med Ctr Dept Pediat Boston MA USA Boston Univ Sch Med Dept Pediat Boston MA 02118 USA Univ Rochester Med Ctr Dept Med Cardiol Unit Rochester NY 14642 USA Brigham & Womens Hosp Dept Med Boston MA 02115 USA Childrens Hosp Dept Cardiol Boston MA 02115 USA Harvard Univ Sch Med Dept Pediat Boston MA 02115 USA Golisano Childrens Hosp Strong Rochester NY USA Univ Rochester Sch Med & Dent Dept Pediat Rochester NY 14642 USA

Background Limited resources;managed care, and advances in technology have led to the suggestion that physicians other than cardiologists be further empowered to perform the initial cardiac evaluation in children with suspected heart disease. To study this strategy, we compared the management decisions of pediatricians with the recommendations of pediatric cardiologists who reviewed the records of the same patients. Methods Sixty-nine patients aged <23 years with suspected heart disease were referred by pediatricians (n = 40) on the inpatient service at Boston Medical Center, for either a cardiology consultation or echocardiography. Two pediatric cardiologists who were blinded to the management decisions and clinical outcomes later reviewed the patient records. Recommendations between the 2 pediatric cardiologist reviewers and the managing pediatricians were compared. Results Pediatricians scheduled significantly fewer cardiology follow-up visits, instituted cardiac medications significantly less often, arranged significantly fewer family meetings to review cardiac findings, and ordered significantly fewer additional cardiac procedures than the pediatric cardiologists. This result was consistent regardless of whether the pediatrician's management decisions were made on the basis of the echocardiogram results only or on the recommendations of a cardiology consultant. The 2 pediatric cardiologist reviewers agreed more often with each. other than either did with the managing pediatricians. Conclusions Pediatricians have different management styles than-pediatric cardiologists for patients with suspected cardiac disease. The effect of these differences on outcome is unknown, and further investigation is warranted.

关键词：医学科学研究中心心脏病学/统计学和数值数据超声心动描记术/统计学和数值数据随访研究心脏缺损先天性/诊断心脏缺损先天性/治疗心脏病/诊断心脏病/治疗心脏杂音/诊断心脏杂音/治疗住院儿科学/统计学和数值数据医师的作用职业家庭关系转诊和会诊/统计学和数值数据青少年成年人儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性

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Evaluating psychiatric morbidity in a general hospital: a two-phase epidemiological survey

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PSYCHOLOGICAL MEDICINE 1999年第4期29卷 823-832页

作者： Martucci, M Balestrieri, M Bisoffi, G Bonizzato, P Covre, MG Cunico, L De Francesco, M Marinoni, MG Mosciaro, C Piccinelli, M Vaccari, L Tansella, M Univ Verona Ist Psichiat I-37100 Verona Italy Univ Udine DPMSC I-33100 Udine Italy

Background. This study aimed to assess psychiatric morbidity and to collect information on disability, life events and family support in a representative sample of patients admitted to a general hospital. Methods. On the basis of information collected in a pilot study a systematic sample of patients consecutively admitted to seven general medical and seven surgical wards of the Academic General Hospital of Verona was selected and interviewed using a two-phase screening procedure and standardized instruments (GHQ-12, HADS, BDQ and CIDI-PHC), All data were analysed using appropriately weighted logistic regression procedures. Results. A total of 1039 patients completed the GHQ-12 and 298 (28.7 %) were high-scorers: 363 patients were interviewed with CIDI-PHC. The prevalence of ICD-10 cases was 26.1%. The most common psychiatric diagnoses were current depression (12.8 %) and generalized anxiety disorder (10.8 %), followed by alcohol related disorders (5 %). A higher prevalence of ICD-10 cases was found in medical wards, among females, patients older than 24 years, unemployed and separated/divorced people. Life events were associated with psychopathology, and so was the number of disability days. Although 49.8 % of ICD-10 cases were identified by the hospital doctors as having a psychological disorder, 23.1% of ICD-10 cases were referred to the liaison psychiatric service. Conclusion, The results of the present study stress the need to collect epidemiologically-based data on psychological disorders and their recognition not only in general practice, but also in general hospital settings, in order to have a more complete picture of the pathways to specialist care.

关键词：医学科学研究中心/统计学和数值数据横断面研究残疾鉴定医院综合/统计学和数值数据发病率意大利/流行病学生活变动事件精神障碍/诊断精神障碍/流行病学精神障碍/心理学病人入院/统计学和数值数据精神病状态评定量表转诊和会诊/统计学和数值数据危险因素社会支持青少年成年人老年人女(雌)性人类男(雄)性中年人

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A framework for evaluating underutilization of health care services

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AMERICAN JOURNAL OF MEDICAL QUALITY 1999年第2期14卷 89-97页

作者： Fetterolf, DE Highmark Inc Pittsburgh PA 15222 USA

Underutilization is becoming increasingly recognized as an area of importance in managed care, where aggressive measures to control overutilization are creating concern among the general public. The author sought solid definition of underutilization and methods for its evaluation in the medical literature but was impressed at the small number of peer reviewed articles on the subject. A review of key issues is discussed, including a number of methods a health plan may use to approach the identification of underutilization within its domain. Methods include the use of "gold standard" population health requirements;statistically defined underutilization;second-order, combined variables;and socially defined underutilization. Sample statistics identified within the author's plan are identified, and recommendations for their implementation and use are made.

关键词：坚持准则卫生服务易得程度卫生服务滥用/统计学和数值数据卫生服务研究/方法管理医疗规划/利用质量指标卫生保健转诊和会诊/统计学和数值数据美国利用情况审核/方法人类

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Assessing young people who deliberately harm themselves

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BRITISH JOURNAL OF PSYCHIATRY 2000年第2期176卷 126-131页

作者： Hurry, J Storey, P Univ London Inst Educ Thomas Coram Res Unit London WC1H 0AL England

Background Many young people who harm themselves have chronic mental hearth or social problems or are at risk of future self-harm or even suicide. The accident and emergency (A&E) clinic is an important gateway to treatment. Aims To describe the psychosocial assessment of 12- to 24-year-old patients attending A&E clinics following deliberate self-harm (DSH) and to identify features of service management and provision which maximise specialist assessment. Method A postal questionnaire wa;sent to a sample of one in three A&E departments in England. In a representative sample of 18 of these hospitals, staff were interviewed and 50 case notes per hospital were examined. Results Psychosocial assessment by non-specialist doctors in A&E departments tended to be of variable quality, focused on short-term risk. Around 43% of patients aged 12-24 were assessed by a specialist;specialist assessment was associated with high admission rates and the presence of on-site psychiatric departments and DSH teams, Conclusions Young DSH patients at risk often go unidentified;as a result their psychological problems may not be treated. Hospitals are frequently unaware of the proportion of patients discharged without adequate assessment. Declaration of interest This work was funded by the Department of Health.

关键词：急诊室医院/组织和管理病史记录/标准病人遴选精神病学/统计学和数值数据转诊和会诊/统计学和数值数据危险性评估自我伤害行为/诊断自我伤害行为/心理学青少年成年人儿童女(雌)性人类男(雄)性

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Association of consultation between generalists and cardiologists with quality and outcomes of heart failure care

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AMERICAN HEART JOURNAL 2003年第6期145卷 1086-1093页

作者： Ahmed, A Allman, RM Kiefe, CI Person, SD Shaneyfelt, TM Sims, RV Howard, G DeLong, JF Univ Alabama Birmingham Sch Med Dept Med Div Gerontol & Geriatr Med Birmingham AL 35294 USA Univ Alabama Birmingham Sch Med Dept Med Div Gen Internal Med Birmingham AL USA Univ Alabama Birmingham Sch Med Dept Med Div Prevent Med Birmingham AL USA Univ Alabama Birmingham Sch Publ Hlth Dept Epidemiol & Int Hlth Birmingham AL 35294 USA Univ Alabama Birmingham Sch Publ Hlth Dept Biostat Birmingham AL 35294 USA Univ Alabama Birmingham Sch Publ Hlth Ctr Aging Birmingham AL 35294 USA Univ Alabama Birmingham Sch Publ Hlth Ctr Outcomes & Effectiveness Educ & Res Birmingham AL 35294 USA Univ Alabama Birmingham Prime Care Geriatr Heart Failure Clin Birmingham AL 35294 USA VA Med Ctr Geriatr Heart Failure Clin Sect Geriatr Birmingham AL USA VA Med Ctr Geriatr Heart Failure Clin Sect Internal Med Birmingham AL USA VA Med Ctr Ctr Geriatr Res Educ & Clin Birmingham AL USA Alabama Qual Aussrance Fdn Birmingham AL USA

Background The appropriate roles for generalists and cardiologists in the care of patients. with heart failure (HF) are unknown. The objective of this retrospective cohort study was to determine whether consultation between generalists and cardiologists was associated with better quality and outcomes of HF care. Methods We studied left ventricular function evaluation (LVFE) and angiotensin-converting enzyme inhibitor (ACEI) use and 90-day readmission and 90-day mortality rates in patients with HF who were hospitalized. Patient care was categorized into cardiologist (solo), generalist (solo), or consultative cares. The processes and outcomes of care were compared by care category using logistic regression analyses fit with generalized linear mixed models to adjust for hospital-related clustering. Results Of the 1075 patients studied, 13% received cardiologist care, 55% received generalist care, and 32% received consultative care. More patients who received consultative care (75%) received LVFE than patients who received generalist care (36%) and cardiologist care (53%;P < .001). Fewer patients who received solo care (54% each) received ACEI compared with 71% of patients who received consultative care (P < .001). After multivariable adjustment, consultative care was associated with higher odds of LVFE than generalist care (adjusted odds ratio [OR], 6.06;95% CI, 3.97-9.26) or cardiologist care (adjusted OR, 2.96;95% CI, 1.70-5.13) care. Consultation was also associated with higher odds of ACEI use compared with generalist (adjusted OR, 2.42;95% CI, 1.42-4.12) or cardiologist (adjusted OR, 2.32;95% CI, 1.14-4.72) care. Compared with patients who received generalist, care, patients who received consultative care had lower odds of 90-day readmission (adjusted OR, 0.54;95% CI, 0.34-0.86). Conclusion Collaboration between generalists and cardiologists, rather than solo care by either, was associated with better HF processes and outcomes of care.

关键词：年龄分布血管紧张素转换酶抑制药/治疗应用心脏病学/统计学和数值数据家庭医学/统计学和数值数据医院死亡率住院比值比结果与过程评价(卫生保健) 医师诊疗模式转诊和会诊/统计学和数值数据回顾性研究心室功能左老年人老年人 80以上女(雌)性人类男(雄)性

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