Patient and professional accuracy of recalled treatment decisions in out‐patient consultations

Aims To test the assumption that professional recall of consultation decisions is valid and more accurate than patient recall of consultation decisions. Methods One hundred and thirty‐four consultations between diabetes specialist nurses and diabetes specialist dietitians in an adult out‐patient diabetes service were audiotaped. Patients and professionals were asked to recall the treatment decisions made immediately after the consultation. Patient participants were also asked to complete the Health Care Climate Questionnaire (HCC). Recalled decisions, by patient and professional participants, were then compared with those extracted from the audio tapes, and with each other. Results The mean duration of consultations was 27 min. Patients recalled a mean of 2.5 (sd 1.4) decisions per consultation, and professionals a mean of 3.2 (sd 1.6) decisions per consultation. A mean of 2.2 (sd 1.1, range 0–4) decisions per consultation were identified on the audiotapes. Patients recalled a mean of 2.3 (sd 1.4, range 0–6) decisions per consultations that could not be found on the tapes, with professionals recalling a mean of 1.7 (sd 1.2, range 0–6) decisions per consultation that could not be found on the tape. More autonomy, as measured by the HCCQ, was correlated with better professional recall (r = 0.17; P < 0.05). Conclusions Both patients and professionals have poor recall of decisions made in diabetes out‐patient consultations. Although the mean professional recall is marginally better than that of the patients, they recall a vast number of unmade decisions and the implications of these being recorded in patients’ notes is substantial.     

Compliance with the recommendations of medical consultants

Compliance with the consultant’s recommendations is one measure of the effectiveness of a consultation. A previous study showed that compliance was better when fewer recommendations were made. In the subsequent year, consultants were encouraged to limit their recommendations to five or fewer. Despite a significant decrease in the number of recommendations, compliance rates remained essentially unchanged (72%). Multivariate analysis demonstrated that the clinical severity of the patient’s disease and the number of associated problems, as well as the types of recommendations, were significant predictors of compliance. Compliance was best for recommendations involving medications (84%) and worst for recommendations involving diagnostic tests (62%). Compliance was also evaluated in the context of a surgeon’s view of the appropriateness of the recommendations. For recommendations felt to be essential to patient care the compliance rate was 75%, but it was only 44% for recommendations judged non-essential (p<0.001). The consulting internist should be aware that the surgeon’s view of the relevance of the recommendations to patient care needs may have an important effect on compliance. Received from the Departments of Medicine and Surgery, Cornell University Medical College, New York, New York. Dr. Ballard was a Henry J. Kaiser Foundation Fellow in General Internal Medicine. Dr. Gold is a Fellow in Cardio-Thoracic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Dr. Charlson is a Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine.     

The service and educational contributions of a general medicine consultation service

General medicine consultation services (GMCS) are perceived as providing routine services in perioperative patient management for referring surgeons. Their potential contributions to improving patient care and resident education have not been well defined. Review of the first year of GMCS in a university teaching hospital showed that only 57% of the consultations were for routine perioperative management of surgical patients. The consultations presented a broad range of medical problems, especially cardiovascular disease (35% of all consultations). Consulting physicians made 2.2 new diagnoses per consult, and 16% of patients required transfer to other services. A GMCS may improve patient care by uncovering new diagnoses, and, by offering them exposure to a variety of medical problems, can improve the consultation skills of students and residents. Received from the Section of General Medicine and Geriatrics, Department of Internal Medicine, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, North Carolina.     

Practical aspects of telehealth: set‐up and preparation for video consultations

The third in a series of articles about the practical aspects of telehealth, this paper gives guidance on suitable setup for video consultations, including layout of rooms, managing sound and image quality, scheduling, testing and best practice in telehealth videoconferencing.     

Outpatient consultation

To define the process of outpatient consultation, the authors conducted a prospective study of 716 consecutive outpatient consultations in a university-based primary care internal medicine practice. The overall consultation rate was 11.9 per 100 patient visits, with 78% of the referrals to other physicians and 22% to non-physician specialists. Consultation rates and patterns of referral varied little between physicians with different levels of experience. Eighteen per cent of the consultations resulted in a no-show by the patient to the consultant. Referring physicians received communications from the consultants 80.5% of the time when appointments were kept. By multivariate regression two variables were shown to be most important in determining the internist’s overall satisfaction: 1) how well the consultant aided the internist in his ongoing management of the patient’s problem, and 2) how well specific questions were addressed by the specialist. Other statistically significant variables were the clarity and promptness of the consultant’s reply, the educational value of the consultation, and specific management recommendations made by the consultant. To improve the consultation process no-shows must be minimized, communication from the consultant maximized, and the interaction between the internist and the consultant bolstered. Received from the Section of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, and Health Care Research Unit, Section of General Internal Medicine and the Evans Memorial Department of Clinical Research and Medicine, Boston University Medical Center, Boston, Massachusetts. Presented in part at the Seventh Annual Meeting of the Society for Research and Education in Primary Care Internal Medicine, May 3–4, 1984.     

Inpatient palliative care consultation for patients with glioblastoma in a tertiary hospital

Glioblastoma (GBM) is an uncommon disease with significant mortality and morbidity, but there is a lack of published evidence on palliative care involvement with this population. This audit highlights the heavy symptom burden, extensive allied health involvement and discharge outcomes of GBM inpatients referred to the palliative care service at The Royal Melbourne Hospital. This information can provide an important framework for further research and also supports the role of multidisciplinary palliative care in the care of patients with GBM.     

神经内科总住院医师急会诊307例分析

目的分析神经内科总住院医师急会诊病例特点,反映总住院医师的工作情况。方法统计福建省立医院神经内科1名总住院医师在2008年12月1日至2009年11月31日急会诊的病例。结果急会诊新病例307例,平均每周会诊6例。急会诊患者中男性173例,女性134例;年龄5个月至93岁,中位年龄58．6岁。急会诊非手术科室有190例（61．89％）,其中心内科、内科ICU分别有50例（16．29％）和47例（15．3l％）。急会诊病例以脑血管病最多见,占总会诊的46．58％（143／307）,主要为急性脑梗死、脑出血、椎基底动脉供血不足（头晕或者眩晕）,少数为短暂性脑缺血发作、陈旧性脑梗死和脑梗死后遗症、蛛网膜下腔出血。精神行为异常32例,占总会诊的10．42％,外科会诊主要是外科手术后出现的各种症状。各种原因引起的抽搐有19例,占总会诊的6．19％。周围神经病变也较常见有13例（4．23％）。结论总住院医师制度,使总住院医师获得了更多的临床实践机会,培养了应用辨证哲学思维指导临床医学思维。     

2011年邵阳市中心医院皮肤科会诊患者临床分析

目的调查我院2011年度皮肤科会诊患者的临床资料,了解住院部皮肤病患者的疾病谱分布情况,为临床会诊提供参考依据。方法将会诊患者的科室、性别、年龄、病种、是否入院发病等临床资料用Excel软件记录并统计。结果会诊科室以内科、儿科为主,皮肤科会诊患者的构成比以变态反应性疾病、感染性疾病、系统性疾病所致皮肤病为主,占所有会诊患者的74.7%。其他皮肤病、性传播疾病、肿瘤性皮肤病分别占14.4%、8.4%、2.1%。结论皮肤科会诊患者仍以变态反应性皮肤病,特别是药物性皮炎为主,提示临床需注意用药安全。系统性疾病所致皮肤病构成比较高,对于皮肤科医师要加强对内科知识的学习。住院患者梅毒血清学阳性的构成比高,在门诊对于高危人群要广泛开展梅毒血清学的筛查工作。     

Introducing personalised care planning into Newham: outcomes of a pilot project

Diabet. Med. 29, 1074–1078 (2012) Aim To explore the feasibility and acceptability of implementing a personalised care planning approach for diabetes care in general practice. Methods A four‐stage care planning process was introduced for diabetes annual review, involving patients (1) being made aware of the new process, (2) attending an appointment to gather clinical data, (3) receiving and reviewing their results and (4) attending a care planning consultation. The latter is a collaborative discussion with the health professional about their response to their results, their goals and desired action plan. Health professionals received specialist training in personalised care planning, including practice observations and feedback. Results Sixty‐six per cent of patients eligible to participate in the project attended both appointments and received an annual review. Of these, 89% also agreed a personalised care plan. Staff reported greater engagement among patients who had read and understood their results. Fourteen per cent of patients reported that they had not agreed a care plan but would have liked one. Patients reported increased confidence in managing their condition with 75% feeling that their ideas and goals were discussed completely. Conclusions Introducing personalised care planning to general practice diabetes care is possible and well received. Our model for implementation of personalised care planning, which includes specialist training for practice teams and ongoing support from local colleagues and health organizations, can help to meet national recommendations for the provision of personalised care plans for people with long‐term conditions. When implementing personalised care planning, efficient administration is vital and behaviour change is necessary for both staff and patients.     

Do neurologists and primary care physicians agree on the extent of specialty involvement of patients referred to neurologists?

OBJECTIVE: Understanding the roles and responsibilities of physicians who manage mutual patients is important for assuring good patient care. Among physicians expressing a preference to involve a neurologist in the care of a patient, we evaluated agreement between neurologists and primary care physicians for the extent of specialty involvement in the evaluation and management of the patient, and the factors influencing those preferences. DESIGN AND SETTING: A self-administered survey containing 3 clinical scenarios was developed with the assistance of a multispecialty advisory board and mailed to a stratified probability sample of physicians. PARTICIPANTS: Six hundred and eight family physicians, 624 general internists, and 492 neurologists in 9 U.S. states. INTERVENTIONS: For each scenario, those respondents who preferred involvement of a specialist were asked about the preferred extent of that involvement: one-time consultation with and without test/medication ordering, consultation and limited follow-up, or taking over ongoing care of the specialty problem as long as it persists. MAIN RESULTS: Survey response rate was 60%. For all 3 scenarios, neurologists preferred a greater extent of specialty involvement compared to primary care physicians (all P <.05). Other physician and practice characteristic factors, including financial incentives, had lesser or no influence on the extent of specialty involvement preferred. CONCLUSIONS: The disagreement between primary care physicians and specialists regarding the preferred extent of specialist involvement in the care of patients with neurological conditions should raise serious concerns among health care providers, policy makers, and educators about whether mutual patient care is coordinated and appropriate.     

Preliminary Data from an Advanced Dementia Consult Service: Integrating Research,Education, and Clinical Expertise

Hospitalized individuals with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. An advanced dementia consultation service was designed, and a pre and post pilot study was conducted in a Boston hospital to evaluate it. Geriatricians and a palliative care nurse practitioner conducted consultations, which consisted of structured consultation, counseling and provision of an information booklet to the family, and postdischarge follow‐up with the family and primary care providers. Individuals aged 65 and older with advanced dementia who were admitted were identified, and consultations were solicited using pop‐ups programmed into the computerized provider order entry (POE) system. In the initial 3‐month period, 24 subjects received usual care. In the subsequent 3‐month period, consultations were provided to five subjects for whom they were requested. Data were obtained from the electronic medical record and proxy interviews (admission, 1 month after discharge). Mean age of the combined sample (N = 29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated that comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), more than five venipunctures (44.8%), and radiological examinations (96.6%). Acknowledging the small sample size, there were trends toward better outcomes in the intervention group, including greater proxy knowledge of the disease, better communication between proxies and providers, more advance care planning, lower rehospitalization rates, and fewer feeding tube insertions after discharge. Targeted consultation for advanced dementia is feasible and may promote greater engagement of proxies and goal‐directed care after discharge.     

Evaluation of HIV Clinical Consultation Provided by the AIDS Education and Training Centers

Abstract

This study examines the effectiveness of HIV clinical consultation offered by the Health Resources and Services Administration (HRSA) funded AIDS Education and Training Centers (AETC) program. The study demonstrates that the consultation provided is effective and useful in providing current treatment recommendations to clinicians in the field caring for HIV-infected patients. The study also shows that individual clinicians seeking clinical consultation from AETC consultants implement the recommendations provided.     

Predicting cardiac complications in patients undergoing non-cardiac surgery

The authors prospectively studied 455 consecutive patients referred to the general medical consultation service for cardiac risk assessment prior to non-cardiac surgery, in order to validate a previously derived multifactorial index in their clinical setting. They also tested a version of the index that they had modified to reflect factors they believed to be important. For patients undergoing major surgery, the original index performed less well in the validation data set than in the original derivation set (p<0.05), but still added predictive information to a statistically significant degree (p<0.05). The modified index also added predictive information for patients undergoing both major and minor surgery, demonstrating an area under the Receiver Operating Characteristic curve of 0.75 (95% confidence interval of 0.70 to 0.80). A simple nomogram is presented which will enable conversion of pretest probabilities into posttest probabilities using the likelihood ratios associated with each risk score. It is recommended that clinicians estimate local overall complication rates (pretest probabilities) for the clinically relevant populations in their settings before they apply the predictive properties (likelihood ratios) demonstrated in this study in order to calculate cardiac risks for individual patients (posttest probabilities). Received from the Departments of Health Administration and Medicine, University of Toronto, and the Division of General Internal Medicine and Clinical Epidemiology, Toronto General Hospital, Toronto, Ontario, Canada. Supported by an Ontario Ministry of Health Research Grant (DM616 and 00621) and the Toronto General Hospital Foundation. Also supported in part by the National Health and Research Development Program (Canada) through a National Health Research Scholar Award to Dr. Detsky.     

Presentation and pattern of symptoms in 382 patients with Glanzmann thrombasthenia in Iran

Glanzmann thrombasthenia (GT) is a rare autosomal recessive disease characterized by prolonged bleeding time with normal platelet count and morphology. It is caused by the quantitative or qualitative deficiency of the platelet glycoprotein IIb-IIIa. In 382 Iranian patients with GT diagnosed at a single center during the period 1969-2001, consanguinity between parents was 86.6%, in accord with the high frequency of intrafamilial marriages in Iran. Almost all patients had had abnormal mucocutaneous bleeding (epistaxis and gum bleeding); at follow-up, 4/5 of the patients had been transfused at least once to control hemorrhagic episodes. As expected, almost all the patients had a normal platelet count while the leukocyte count was increased in 19.3%. Among women, an unexpected low rate of pregnancies was observed.     

Impact of new guidelines on physicians’ ordering of preoperative tests

OBJECTIVE: To compare the number of preoperative tests ordered for elective ambulatory surgery patients during the 2 years before and the 2 years after the establishment of new hospital testing guidelines. MEASUREMENTS: The patterns of preoperative testing by surgeons and a medical consultant during the 2 years before and the 2 years after the establishment of new guidelines at one orthopedic hospital were reviewed. All tests ordered preoperatively were determined by review of medical records. Preoperative medical histories, physical examinations, and comorbidities were obtained according to a protocol by the medical consultant (author). Perioperative complications were determined by review of intraoperative and postoperative events, which also were recorded according to a protocol. MAIN RESULTS: A total of 640 patients were enrolled, 361 before and 279 after the new guidelines. The mean number of tests decreased from 8.0 before to 5.6 after the new guidelines ( p =.0001) and the percentage decrease for individual tests varied from 23% to 44%. Except for patients with more comorbidity and patients receiving general anesthesia, there were decreases across all patient groups. In multivariate analyses only time of surgery (before or after new guidelines), age, and type of surgery remained statistically significant ( p =.0001 for all comparisons). Despite decreases in surgeons' ordering of tests, the medical consultant did not order more tests after the new guidelines ( p =.60) The majority of patients had no untoward events intraoperatively and postoperatively throughout the study period, with only 6% overall requiring admission to the hospital after surgery, mainly for reasons not related to abnormal tests. Savings from charges totaled $34,000 for the patients in the study. CONCLUSIONS: Although there was variable compliance among physicians, new hospital guidelines were effective in reducing preoperative testing and did not result in increases in untoward perioperative events or in test ordering by the medical consultant.     

社区医院应用网络化心电系统的临床意义

目的：探讨社区医院应用网络化心电系统的临床意义。方法社区医院基层心电医生筛选需要会诊的心电图或疑难心电图,利用网络化心电系统将心电信息上传到我院心电网络会诊中心。我院心电会诊中心的专职医师对心电图图谱进行会诊,会诊结果反馈回社区医院。结果本研究共收集到心电图378份,共发现异常心电图213例,可能发生恶性事件的心电图29例。经分析发现漏诊184例（48．68％）、误诊45例（11．90％）。结论网络化心电系统的应用使社区医院能够及时发现危重心电图,纠正漏诊和误诊,减少恶性心脏事件的发生;同时,解决了基层心电医生诊断力量薄弱的问题,完善了社区医院的医疗服务功能,取得了良好成效。     

Programa de consulta electrónica universal (e-consulta) de un servicio de cardiología. Resultados a largo plazo

Introduction and objectivesMany health systems have initiated electronic consultation (e-consultation) programs, although little is known about their impact on accessibility, safety, and satisfaction. The aim of this study was to assess the clinical impact of the implementation of an outpatient care model that includes an initial e-consultation and to compare it with a one-time face-to-face consultation model.MethodsWe selected patients who visited the cardiology service at least once between 2010 and 2019. Using an interrupted time series regression model, we analyzed the impact of incorporating e-consultation into the health care model (started in 2013), and evaluated waiting times, emergency services, hospital admissions, and mortality.ResultsWe analyzed 47 377 patients: 61.9% were attended in e-consultation and 38.1% in one-time face-to-face consultations. The waiting time for care was shorter in the e-consultation model (median [IQR]: 7 [5-13] days) than in the face-to-face model (median [IQR]: 33 [14-81] days), P < .001. The interrupted time series regression model showed that the introduction of e-consultation substantially decreased waiting times, which held steady at around 9 days, although with slight oscillations. Patients evaluated via e-consultation had fewer hospital admissions (0.9% vs 1.2%, P = .0017) and lower mortality (2.5% vs 3.9%, P < .001).ConclusionsAn outpatient care program that includes an e-consultation reduced waiting times significantly and was safe, with a lower rate of hospital admissions and mortality in the first year.     

Communication breakdown in the outpatient referral process

OBJECTIVE: To evaluate primary care and specialist physicians' satisfaction with interphysician communication and to identify the major problems in the current referral process. DESIGN: Surveys were mailed to providers to determine satisfaction with the referral process; then patient-specific surveys were e-mailed to this group to obtain real-time referral information. SETTING: Academic tertiary care medical center. PARTICIPANTS: Attending-level primary care physicians (PCPs) and specialists. MEASUREMENTS AND MAIN RESULTS: The response rate for mail surveys for PCPs was 57% and for specialists was 51%. In the mail survey, 63% of PCPs and 35% of specialists were dissatisfied with the current referral process. Respondents felt that major problems with the current referral system were lack of timeliness of information and inadequate referral letter content. Information considered important by recipient groups was often not included in letters that were sent. The response rate for the referral specific e-mail surveys was 56% for PCPs and 53% for specialists. In this e-mail survey, 68% of specialists reported that they received no information from the PCP prior to specific referral visits, and 38% of these said that this information would have been helpful. In addition, four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists. CONCLUSIONS: Substantial problems were present in the referral process. The major issues were physician dissatisfaction, lack of timeliness, and inadequate content of interphysician communication. Information obtained from the general survey and referral-specific survey was congruent. Efforts to improve the referral system could improve both physician satisfaction and quality of patient care.     

Follow-up loss in smoking cessation consultation: can we predict and prevent it?

BackgroundCigarette smoking has a considerable health and economic burden in modern society, with increased risk of morbidity and mortality. Therefore, smoking cessation policies and medical treatments are essential. However, cessation rates are low and the abandonment of the consultation is common. The identification of characteristics that may predict adherence will help defining the best treatment strategy. This study aimed to identify predictors of follow-up loss in smoking cessation consultation.MethodsWe made a retrospective observational study, including a cohort of patients who started smoking cessation consultation (April-December 2018). Clinical data from consultations was collected and analyzed with IBM SPSS Statistics (SPSS, RRID:SCR_002865).ResultsA total of 175 patients was selected (41.1% female), with a mean age of 53±12 years. Eighty-five patients (48.6%) were discharged for abandonment. They had a median pack-year unit 38±36 (P=0.011), Fagerström and Richmond scores of 5±2 and 7±2, respectively. There was an association between women (P<0.001), younger age (P<0.001), depression/anxiety (P=0.023), lower smoking load (P=0.019), starting the treatment in the first appointment (P=0.004) and the abandonment of the consultation. In binary logistic regression, younger age (less than 50 years) (OR =4.39; 95% CI: 1.99–9.70), starting the treatment in the first appointment (OR =3.04; 95% CI: 1.44–6.42) and depression/anxiety (OR =2.30; 95% CI: 1.08–4.88) remained independent predictors of loss in follow-up.ConclusionsWomen, younger age, depression/anxiety, lower smoking load and starting treatment in the first appointment are predictors of follow-up loss, so, these patients may benefit from more frequent evaluations and intensive cognitive approach. This study also raises awareness about the adequate timing to start pharmacological support for smoking cessation.