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Assessing young people who deliberately harm themselves

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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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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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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Monitoring referral and treatment in soft tissue sarcoma -: Study based on 1,851 patients from the Scandinavian Sarcoma Group Register

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ACTA ORTHOPAEDICA SCANDINAVICA 2001年第2期72卷 150-159页

作者： Bauer, HCF Trovik, CS Alvegård, TA Berlin, Ö Erlanson, M Gustafson, P Klepp, R Möller, TR Rydholm, A Sæter, G Wahlström, O Wiklund, T Univ Lund Hosp Reg Tumor Register Scandinavian Sarcoma Grp SE-22185 Lund Sweden Karolinska Hosp Dept Orthoped Oncol Serv SE-17176 Stockholm Sweden Haukeland Hosp Dept Orthoped NO-5021 Bergen Norway Univ Lund Hosp Dept Oncol SE-22185 Lund Sweden Sahlgrenska Hosp Dept Orthoped SE-41345 Gothenburg Sweden Univ Umea Hosp Dept Oncol SE-90185 Umea Sweden Univ Lund Hosp Dept Orthoped SE-22185 Lund Sweden Reg Hosp Dept Oncol NO-7006 Trondheim Norway Univ Lund Hosp Dept Reg Tumour Register E-22185 Lund Sweden Norwegian Radium Hosp Dept Oncol NO-0310 Oslo 3 Norway Linkoping Univ Hosp Dept Orthoped SE-58185 Linkoping Sweden Univ Helsinki Hosp Dept Radiotherapy & Oncol FI-00290 Helsinki Finland

This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The median age at diagnosis was 65 years and the male-to-female ratio was 1.1:1, One third of the tumors were subcutaneous, one third deep, intramuscular and one third deep, extramuscular, The median size was 7 (1-35) cm and 75% were high grade (III-IV). Metastases at presentation were diagnosed in 8% of the patients, Two thirds of STS patients were referred before surgery and the referral practices have improved during the study. The preoperative morphologic diagnosis was made with fine-needle aspiration cytology in 81%, core-needle biopsy in 9% and incisional biopsy in 10%. The frequency of amputations has decreased from 15% in 1986-88 to 9% in 1995-1997, A wide surgical margin was achieved in 77% of subcutaneous and 60% of deep-seated lesions, Overall, 24% of operated STS patients had adjuvant radiotherapy. The use of such therapy at sarcoma centers increased from 20% 1986-88 to 30% in 1995-97, Follow-up has been reported in 96% of the patients. The cumulative local recurrence rate was 0.20 at 5 years and 0.24 at 10 years. The 5-year metastasis-free survival rate was 0.70.

关键词：活组织检查化学疗法辅助随访研究放射疗法辅助复发转诊和会诊/统计学和数值数据登记肉瘤/流行病学肉瘤/病理学肉瘤/外科学肉瘤/治疗斯堪的纳维亚/流行病学存活率青少年成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Provision of primary care by office-based rheumatologists - Results from the National Ambulatory Medical Care surveys, 1991-1995

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ARTHRITIS AND RHEUMATISM 1999年第3期42卷 409-414页

作者： Ward, MM Vet Affairs Palo Alto Hlth Care Syst Palo Alto CA 94304 USA Stanford Univ Sch Med Stanford CA 94305 USA

Objective. To determine the extent to which office-based rheumatologists provide primary care to patients without rheumatic diseases or provide principal care to patients with rheumatoid arthritis (RA), Methods. The National Ambulatory Medical Care Survey was used to determine national probability estimates of the nature and types of conditions treated by office-based rheumatologists in 1991-1995. At each of 1,074 patient visits, the rheumatologists recorded up to 3 diagnoses and 3 patient-reported reasons for the visit, as well as information on the treatments provided at the visit. Results. In only 9.8% of new consultations and 11.9% of return visits was neither a rheumatic disease diagnosis nor a musculoskeletal complaint recorded, indicating that the rheumatologist was likely acting as a primary care provider at a minority of patient visits. Among continuing patients with RA, the patient's primary reason for the visit was something other than a musculoskeletal complaint in only 9.9% of visits, and any nonrheumatic complaint was recorded in 30.4% of visits, indicating that at only some visits was the rheumatologist acting as the principal caregiver. In addition, only 31.1% of visits included the provision of medication for a nonrheumatic condition. Conclusion. In 1991-1995, most visits to rheumatologists involved the provision of specialized or consultative care to patients with rheumatic diseases or musculoskeletal complaints, and few visits were made by patients without either indication. Provision of principal care by rheumatologists to patients with RA is not currently widespread.

关键词：门诊医疗/人力门诊医疗/利用卫生保健调查诊室就医/利用病人接受卫生保健的程度/统计学和数值数据医师的作用初级卫生保健/人力初级卫生保健/利用转诊和会诊/统计学和数值数据风湿病学/人力风湿病学/统计学和数值数据美国青少年成年人女(雌)性人类男(雄)性中年人

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Neurologic consultations in children with systemic cancer

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PEDIATRIC NEUROLOGY 1999年第2期20卷 121-124页

作者： Antunes, NL De Angelis, LM Mem Sloan Kettering Canc Ctr Dept Neurol New York NY 10021 USA

The frequency and severity of neurologic symptoms in children with systemic cancer is unknown. The authors reviewed the records of children with systemic cancer for whom a neurologic consultation was requested between 1993 and 1996, The 157 patients had 161 malignancies and 205 consultations. Leukemia (59) and lymphoma (34) were the most common malignancies. The 68 solid tumors included neuroblastoma (13), Ewing's sarcoma, and rhabdomyosarcoma (10 each). In constrast to adults, in whom back pain and altered mental status are the most common reasons for neurologic consultation, headache (33) and seizures (29) were the most common symptoms in children. Structural lesions were present in 84% of patients with headache and focal deficit and in 14% of patients with isolated headache. Structural disease was identified in 37% of children with seizures. Neurologic signs were caused by complications of cancer therapy in 70 instances and to direct tumor invasion of the nervous system in 60, In 71 consultations, neurologic symptoms could not be attributed to cancer or its treatment. The spectrum of neurologic symptoms in children with cancer differs from adults and requires the consulting neurologist to have a thorough knowledge of childhood cancer and its effects on the nervous system, (C) 1999 by Elsevier Science Inc. All rights reserved.

关键词：行为症状/病因学运动障碍/病因学肿瘤/并发症肿瘤/治疗神经系统疾病/病因学转诊和会诊/统计学和数值数据回顾性研究发作/病因学感觉障碍/病因学青少年成年人儿童儿童学龄前女(雌)性人类婴儿男(雄)性

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Direct access day case oral surgery

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BRITISH DENTAL JOURNAL 2000年第8期188卷 452-456页

作者： Joshi, A Doyle, L Worthington, HV Rood, JP Manchester Royal Infirm Dept Oral & Maxillofacial Surg Manchester M13 9WL Lancs England Univ Manchester Dent Hosp Dept Dent Med & Surg Manchester M15 6FH Lancs England GKT Sch Dent London SE5 9RW England

Objective To compare the effectiveness of direct access referrals with standard letter referrals, and also assess the impact of the direct access system on the primary care provider, secondary sector and from the patients perspective. Design Surgical and anaesthetic guidelines were agreed and 12 general dental practitioners were recruited to participate in the study. Each practitioner was given 100 envelopes which contained randomly allocated 50 direct and 50 standard referrals. For direct referrals, GDPs completed a pre-operative assessment and obtained an operation date by telephone from the day case unit while the patient was in the surgery. The clinical history sheet was fared to the day unit and the radiographs posted. The only contact the patient had with the hospital was on the day of surgery. Standard referral patients were referred in the traditional way with a referral letter being sent to an out-patient clinic. Evaluation of the effectiveness of the direct referral system versus standard letter method were made via completion of questionnaires by the patients, dental practitioners, hospital clinicians, day case anaesthetist and co-ordinator. Setting The study was carried out over 2 years commencing in 1997 at the Oral Surgery Day Case Unit at Manchester Royal Infirmary. Results A greater number of direct access referrals (409;90%) were treated in comparison with (312;75%) standard referrals IP < 0.001). Eighty nine per cent of direct access records were adequate pre-operatively. More than 70% of dentists and hospital clinicians preferred the direct access referral method. Sixty-three per cent of standard letter patients were satisfied with their mode of referral compared with 87% of direct access patients. Conclusions Given appropriate guidelines dental practitioners are able to refer directly to oral surgery day case operation lists. This has proved to be the favoured method of referral for dental practitioners, the secondary sector and patients.

关键词：门诊外科手术/统计学和数值数据医务工作者的态度牙科医院/统计学和数值数据开业医生牙科/组织和管理开业医生牙科/统计学和数值数据口腔外科手术/统计学和数值数据病人满意度随机分配转诊和会诊/组织和管理转诊和会诊/统计学和数值数据外科口腔/组织和管理青少年成年人人类中年人

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Referral patterns and the referral system for oral surgery care. Part 1: General dental practitioner referral patterns

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BRITISH DENTAL JOURNAL 2000年第3期188卷 142-145页

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

Objective To investigate current GDP oral surgery referral patterns given the anticipated change since the introduction by the General Dental Council of the specialty of surgical dentistry. Design Postal questionnaire. Setting 400 GDPs in Greater Manchester. Results 84% participation rate. 69% of dentists made a referral because of anticipated difficulty of surgery and 49% because of the complex nature of the patients' medical history. Practitioners who had undergone some oral surgery postgraduate training were more likely to undertake more surgery in their practices (P < 0.01) and to refer more patients for specialist care (P < 0.05). While female practitioners rated their own surgical confidence less highly than male practitioners (P < 0.001), and younger practitioners less than their older colleagues (P > 0.05), there was no significant difference in the number ofreferrals made. Conclusion The most common reasons for referral were the anticipated difficulty of surgery and patient medical compromise. There was a wide variation between practitioners in the number of patients referred for specialist care, Postgraduate oral surgery training was identified as a factor contributing to this variation. Other practitioner variables, such as sex, experience and type of practice were not found to contribute.

关键词：教育牙科继续/统计学和数值数据英格兰开业医生牙科/组织和管理开业医生牙科/统计学和数值数据转诊和会诊/统计学和数值数据外科口腔/教育外科口腔/统计学和数值数据成年人老年人女(雌)性人类男(雄)性中年人

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Policy of consultant oral and maxillofacial surgeons towards removal of miniplate components after jaw fracture fixation: pilot study

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BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY 1999年第2期37卷 110-112页

作者： Matthew, IR Frame, JW Univ Birmingham Sch Dent Dept Oral Surg Birmingham B4 6NN W Midlands England

A pilot study was undertaken to find out the policy of the 23 consultant oral and maxillofacial surgeons in the West Midlands towards removal of miniplates after jaw fractures had healed, All 23 replied, Two consultants did not use miniplates;the other 21 respondents used titanium systems, and two also used a stainless steel system, None of the 21 respondents routinely removed all miniplates. The estimated total of miniplates removed after the fracture had healed ranged between 5% and 40% (mode 5%), The main indications for removal were wound infection or dehiscence, before construction of a prosthesis, patients' concern about permanent retention of an implant, and thermal conductivity, We conclude that miniplates and screws are removed mainly to treat symptoms caused by the implants.

关键词：试点项目转诊和会诊/统计学和数值数据外科口腔/统计学和数值数据外科伤口裂开/病因学外科伤口裂开/外科学外科伤口感染/病因学外科伤口感染/外科学

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Referral patterns to a university-based cardiac rehabilitation program

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AMERICAN JOURNAL OF CARDIOLOGY 1999年第2期83卷 252-+页

作者： Bittner, V Sanderson, B Breland, J Green, D Univ Alabama Dept Med Div Cardiovasc Dis Birmingham AL 35294 USA Univ Alabama Div Data Resources Birmingham AL 35294 USA

Referral rates to our cardiac rehabilitation program among patients hospitalized for coronary heart disease were computed over an 18-month period. Only 8.7% of eligible patients were referred, suggesting that more education targeting physicians, patients, and insurers is needed and barriers to participation must be systematically addressed.

关键词：年龄因素亚拉巴马健康状况心脏病/康复医院大学/统计学和数值数据保险健康 Logistic模型转诊和会诊/统计学和数值数据成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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