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Will the GP commissioner role make a difference? Exploratory findings from a pilot project offering complementary therapy to people with musculo-skeletal problems

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Complementary Therapies in Medicine 1999年第3期7卷 170-174页

作者： Emanuel, J. Education for Primary Health Care Faculty of Education University of Manchester Manchester M13 9PH Oxford Road United Kingdom

The paper focuses on the interprofessional relationships which developed between general practitioners (Gps) and complementary practitioners (Cps) during a pilot project where GPs referred to acupuncturists, osteopaths and chiropractors. It is based on interviews with GPs and CPs, that took place at the beginning and end of an evaluative study on patients referred with musculoskelal conditions. Referrals to hospital orthopaedic outpatients departments and pain clinics were also examined. The most common relationship that developed was where the GP delegated responsibility for treatment to the CP. One CP and GP developed a more interactive relationship which included a shared diagnostic role. The NHS reforms offer opportunities for different types of working relationships to develop between health professionals. They also offer opportunities for professionals who have not traditionally worked in the NHS to do so. The findings discussed here are exploratory. Further research to identify the types of relationships developing between Cps and Gps and to establish whether the type of relationship has an impact on secondary referrals and treatment outcomes is recommended.

关键词：补充疗法/方法家庭医学/方法职业间关系领导肌骨骼疾病/治疗试点项目转诊和会诊/统计学和数值数据女(雌)性人类男(雄)性

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Problems with Recruitment in a Randomized Controlled Trial of Counselling in General Practice: Causes and Implications

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Journal of Health Services Research & Policy 1996年第2期1卷 77-80页

作者： Fairhurst, Karen Dowrick, Christopher Department of General Practice University of Edinburgh Edinburgh United Kingdom Department of Primary Care University of Liverpool United Kingdom

To evaluate the effectiveness of counselling in the management of minor psychiatric morbidity in general practice, and to explore the reasons for difficulties in recruiting patients to such an evaluation. We attempted to conduct a randomized controlled trial of counselling in eight general practices in one NHS family health services authority area in England. Having experienced significant problems recruiting patients, we conducted semi-structured telephone interviews (n = 8) with participating GPs to explore the reasons for these difficulties. Five months after the start of the study only one patient had been recruited. The main reasons identified as contributing to the recruitment problems were: General practitioners' motivation for involvement in the study;their ethical doubts about the randomization process;the perceived lack of a viable non-counselling intervention;and their existing practical commitment to counselling. Although methodological modification might enhance the potential for success in future studies of this sort, more fundamental difficulties concerning general practitioners' attitudes to research and their professional responsibilities lie at the heart of our recruitment problems. © 1996, SAGE Publications. All rights reserved.

关键词：医务工作者的态度咨询/利用家庭医学/组织和管理大不列颠卫生服务研究/方法精神障碍动机病人遴选转诊和会诊/统计学和数值数据公费医疗人类

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Public hospital pregnancy termination services: are we meeting demand?

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AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999年第5期23卷 525-527页

作者： Black, K Fisher, J Grover, S Royal Hosp Women Melbourne Vic 3053 Australia Univ Melbourne Key Ctr Women Hlth Soc Parkville Vic 3052 Australia

Objectives: To identify the sociodemographic characteristics of women seeking termination of pregnancy through a public hospital service and explore issues of accessibility to the service. Method: An audit of the Pregnancy Advisory Service (PAS) at the Royal Women's Hospital in Melbourne from January to March 1996. Data were collected from 1,088 intake forms of women seeking an abortion. Results: The women were of low socioeconomic status, with 437 (40.2%) living on a government pension or benefit and 55.6% holding a Health Benefits Card. However, only 33.8% were given an appointment for an abortion in the public clinic, with most (63.7%) referred to private services. Conclusions: The demand for this public hospital abortion service exceeds its capacity and economically disadvantaged women are required to seek abortion in private services. Implications: There is a role for regional health authorities to ensure adequate distribution of public hospital pregnancy termination services.

关键词：流产人工/利用方差分析计划生育服务/利用卫生服务易得程度医院公立门诊部医院/利用转诊和会诊/统计学和数值数据社会经济因素维多利亚青少年成年人女(雌)性人类妊娠

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Supplier-induced demand for pastoral care services in the general hospital: a natural experiment.

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Journal of pastoral care 1990年第3期44卷 266-270页

作者： Gartner, J. Lyons, J.S. Larson, D.B. Serkland, J. Peyrot, M. Department of Pastoral Counseling Loyola College in Maryland Columbia MD 21045.

Assesses the effects the elimination of a pastoral care training program and a reduction in staff had on referral rates for pastoral care. Results showed a decrease in referrals initiated by pastoral care staff but an increase in pastoral care referrals initiated by medical staff and patients. Notes that when pastoral care staff were less available, the demand for their services became more apparent.

关键词：宗教事务科医院/利用芝加哥医院病床数 500张以上医院综合/利用牧师心理治疗/教育转诊和会诊/统计学和数值数据

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Referrals for dental general anaesthetics - How many really need GA?

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BRITISH DENTAL JOURNAL 1999年第8期187卷 440-443页

作者： Tyrer, GL Birch Hill Hosp Community Dent Off Rochdale OL12 9QB England

Aim To fmd out how many patients for whom dental general anaesthesia was requested actually needed it in order to complete treatment. Design Analysis of clinical outcomes supported by telephone canvassing of parents. Method In summer 1998, eighty two child patients were seen in the Community Dental Service in Rochdale with a request for the provision of dental general anaesthesia (DGA) for the extraction of teeth. Their ages ranged from 3 to 14 years and all were required to attend for a pre-anaesthetic visit. Unless objective indicators of a need for DGA applied, the parents and children were actively discouraged from having DGA, and the alternative of local anaesthetic (LA) was offered. Clinical outcomes and parent satisfaction were recorded after treatment was finished. Results In 75% of cases it proved possible to complete the extractions without need for DGA;in the 10% of cases where DGA was necessary, it was to deal with the sequelae of dental caries. Fifteen percent of subjects failed to complete treatment. Subjects found to have a need for DGA tended to be younger and with treatment required in more than one sextant. Pain as a presenting symptom, young age and multiple treatment needs were found to be poor predictors of need for DGA and did not automatically preclude successful treatment without DGA. The satisfaction ascertained from users of the service was high and explanation of proposed treatments, especially the comparative risks and benefits of DGA versus LA, was well received. Conclusion There is score for significant reduction. in provision of dental general anaesthesia if current professional guidelines are followed.

关键词：年龄因素麻醉牙科/统计学和数值数据麻醉全身/统计学和数值数据麻醉局部/统计学和数值数据龋齿/治疗采访(主题) 病人遴选转诊和会诊/统计学和数值数据危险性评估拔牙治疗结果青少年儿童儿童学龄前人类

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Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable?

JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON

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JOURNAL OF THE ROYAL COLLEGE OF PHYSICIANS OF LONDON 1999年第3期33卷 255-259页

作者： McGloin, H Adam, SK Singer, M UCL Sch Med Rayne Inst Bloomsbury Inst Intens Care MedDept Med London WC1E 6JJ England UCL Hosp NHS Trust Intens Care Unit London England

Objectives: (i) To determine the incidence of unexpected deaths occurring on general wards, and whether any were potentially avoidable;(ii) to assess whether the quality of care on general wards prior to admission to intensive care affected subsequent outcome. Design: Six-month audit in teaching hospital. Review of medical, nursing and physiotherapy notes, bedside charts and laboratory data in ward patients either dying unexpectedly tie not having a prior 'do not resuscitate' order) or requiring intensive care unit (ICU) admission. Panel assessment of quality of ward care prior to unexpected ward death or ICU admission. Subjects: Adult general ward patients admitted to ICU or dying unexpectedly. Outcome measures: ICU and hospital mortality. Results: (i) In the six-month study period, 317 of the 477 hospital deaths occurred on the general wards, of which 20 (6%) followed failed attempts at resuscitation. Thirteen of these unexpected deaths were considered potentially avoidable: gradual deterioration was observed in physiological and/or biochemical variables, but appropriate action was not taken;(ii) in the same period, 86 hospital inpatients were admitted on 98 occasions to the ICU, 31 of whom received suboptimal care pre-ICU admission due either to non-recognition of (the severity of) the problem or to inappropriate treatment. Both ICU (52% vs 35%) and hospital (65% vs 42%) mortality was significantly higher in these patients compared to well managed patients (p <0.0001). Conclusions: Patients with obvious clinical indicators of acute deterioration can be overlooked or poorly managed on the ward. This may lead to potentially avoidable unexpected deaths or to a poorer eventual outcome following ICU admission. Early recognition and correction of abnormalities may result in outcome benefit, but this requires further investigation.

关键词：年龄分布死亡原因猝死/流行病学大不列颠医院死亡率/发展趋势发病率重症监护病房/利用医学审核结果评价(卫生保健) 病房/标准转诊和会诊/统计学和数值数据青少年成年人老年人儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性中年人

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After-hours telephone calls to obstetrician-gynecologists

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OBSTETRICS AND GYNECOLOGY 2000年第3期96卷 459-464页

作者： Smulian, JC Reeve, AD Donoghue, EA Knuppel, RA McCann, TO Ananth, CV Univ Med & Dent New Jersey Robert Wood Johnson Med Sch St Peters Univ Hosp Dept Obstet Gynecol & Reprod Sci New Brunswick NJ 08903 USA St Peters Univ Hosp Dept Pediat New Brunswick NJ USA

Objective: To characterize the pattern, content, and management of after-hours telephone interactions between obstetrician-gynecologists and patients. Methods: In a prospective observational study, 12 resident and nine private physicians practicing obstetrics and gynecology completed data cards for after-hours telephone interactions with patients. Chief complaints were categorized as related to either women's health or primary care and on whether women were pregnant postpartum or not pregnant. Triage dispositions (evaluate now, office follow-up, or home care) were compared between groups. Women also were asked what they would have done if they had been unable to contact their physicians by telephone. Results: One hundred ninety-two of 276 calls evaluated (69.6%) were from pregnant women, 20 (7.2%) were from postpartum women, and 64 (23.3%) were from nonpregnant women. Calls were related to primary care health issues in 24.1% (n = 45) of pregnant women, 40% (n = 8) of postpartum women, and 28.1% (n = 18) of nonpregnant women. There were no differences between residents and private physicians in the proportion of women triaged to immediate evaluation for pregnancy (35.1% [n = 40] versus 41.9% [n = 31], P = .74) or postpartum (11.1% [n = 1] versus 10% [n = 1], P = .96) problems. Among 139 women triaged to office follow-up, 41% (n = 57) would have come to the hospital for emergency evaluation if they had been unable to reach their physicians. Conclusion: Resident and private obstetrician-gynecologists provide primary care and women's health care advice during after-hours telephone calls from patients. More than one third of after-hours telephone calls from pregnant women are triaged to immediate evaluation. (Obstet Gynecol 2000;96:459-64. (C) 2000 by The American College of Obstetricians and Gynecologists.).

关键词：妇科学/统计学和数值数据产科学/统计学和数值数据初级卫生保健/统计学和数值数据前瞻性研究转诊和会诊/统计学和数值数据电话/统计学和数值数据伤病员分拣工作安排忍受成年人女(雌)性人类婴儿新生中年人妊娠

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Does general practitioner gatekeeping curb health care expenditure?

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Journal of Health Services Research and Policy 2000年第1期5卷 22-26页

作者： Delnoij, D. Van Merode, G. Paulus, A. Groenewegen, P. NIVEL 3500 BN Utrecht PO Box 1568 Netherlands

Objectives: It is generally assumed that health care systems in which specialist and hospital care is only accessible after referral by a general practitioner (GP) have lower total health care costs. In this study, the following questions were addressed: do health care systems with GPs acting as gatekeepers to specialized care have lower health care expenditure than those with directly accessible specialist care? Does health care expenditure increase more rapidly in countries without a referral system than in those with the GP acting as a gatekeeper? Methods: Multiple regression analyses on total and ambulatory health care expenditure in 18 OECD countries. Results: Analyses showed only one statistically significant effect (P < 0.05) in countries with gatekeeping GPs: ambulatory care expenditure has increased more slowly than in non-gatekeeping systems. No significant effects of gatekeeping were found on the level of ambulatory care costs, or on the level or growth of total health care expenditure. As in earlier studies, the most important factor influencing aggregate health care costs and their growth is gross national product (GNP), followed by the share of public funding. Relationships that exist at a micro level (such as lower costs with a gatekeeping primary care doctor) did not show up in aggregate data at a macro level. Conclusions: Gatekeeping systems appear to be better able to contain ambulatory care expenditure. More research is necessary to understand micro level mechanisms and to distinguish the effects of gatekeeping from other structural aspects of health care systems.

关键词：费用控制/经济学费用控制/统计学和数值数据欧洲医疗服务限制/经济学医疗服务限制/统计学和数值数据卫生经费支出/统计学和数值数据日本医师的作用医师家庭/经济学医师家庭/统计学和数值数据转诊和会诊/经济学转诊和会诊/统计学和数值数据回归分析美国人类

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