Referrals to psychiatrists. Assessing the communication interface between psychiatry and primary care

The Study of Outpatient Referral Patterns was conducted in 1998 to examine the nature of the communication relationship between psychiatrists and primary care physicians regarding outpatient referrals. Nationally representative psychiatrists were surveyed (N = 542) regarding their aggregate experience with outpatient referrals from non-psychiatric physicians in the previous 60 days. Data regarding frequency and type of information and mode of communication were gathered. Results indicate that primary care physicians represent a significant source of referrals to psychiatrists and that psychiatrists are generally satisfied with the communication interface with the referring physicians. Psychiatrists' level of satisfaction was related to the quantity and quality of information provided by referring physicians.     

A prospective analysis of inpatient consultations to a gastroenterology service

The provision of a formal consultation service for inpatients between subspecialists is little studied. We prospectively surveyed the pattern of inpatient consultations from hospital-based generalists and surgeons to the gastroenterology (GI) service for inpatients in a large urban teaching hospital over a 5 month period. There are two GI consultants/attendings and five GI registrars/fellows on the service. A formal consultation is made by the requesting team to the GI service using the hospital computer network. All referrals over a 5 month period were prospectively analysed. 242 consecutive inpatient referrals were sent to the GI service over 5 months. Average age was 56 years, 48.8% males. 32 consultants/attendings from other disciplines sent referrals. Most patients were seen within one working day. Urgent referrals were seen without delay. The commonest reasons for referral were abdominal pain (15.8%), percutaneous endoscopic gastrostomy (PEG) tube insertion (13.6%), diarrhoea (12.8%), abnormal liver blood tests (10%), nausea and vomiting (8.2%), anaemia (6.2%), and melaena (4.9%). Iatrogenic diseases accounted for 6.2% of consultations. Ongoing patient care was assumed by the GI team in 9.5% of referrals. 15.3% required a second consultation visit before discharge. 22.7% of referrals were followed in the GI outpatients' clinic after discharge. 51.2% underwent an endoscopic procedure. 13.6% of referrals were for PEG tube insertion. A quarter of these were considered unsuitable for immediate PEG tube insertion. Subspecialty consultation provides an expert opinion, encourages discussion and learning, and improves patient care. In our experience, the provision of specialist advice and reassurance often speeded up a patient's work-up and expedited discharge. However, evaluating referral patients and subsequently providing ongoing inpatient and outpatient care and provision of endoscopy for these referrals contributes significantly to the workload of the GI service.     

General practice based physiotherapy: its use and effect on referrals to hospital orthopaedics and rheumatology outpatient departments.

BACKGROUND. In November 1992, a pilot scheme was established in Doncaster to provide an on-site physiotherapy service in six non-fundholding general practices covering a population of approximately 44,000 people. AIM. The aim of the pilot scheme was to transfer a hospital-based physiotherapy service, to which general practitioners had direct access, to a primary care setting and to reduce referrals to an orthopaedics outpatient department. METHOD. Use of physiotherapy services and referrals to orthopaedics and rheumatology before and during the first year of the scheme were monitored. Comparisons were made with data over the same time periods for general practices that were not in the scheme. The location of management of patients referred to physiotherapy was monitored for an eight-month period during the scheme. RESULTS. In the first year the scheme had a utilization rate of 31 per 1000 patients in the participating practices, representing a 164% increase over the hospital-based physiotherapy utilization rate for the year prior to the scheme. Eight per cent of physiotherapy patients received hospital-based treatment during the scheme. Changes in hospital outpatient referral rates attributable to the scheme were reductions of 8% to the orthopaedics department and 17% to the rheumatology department. CONCLUSION. The increase in the use of the physiotherapy service was possibly caused, in part, by general practitioners sending patients to on-site physiotherapy who previously would have been referred to orthopaedics and, largely, by an increase in the treatment of patients who previously would not have been referred to hospital. Physiotherapy based in general practice can be a substitute for hospital-based physiotherapy and can contribute to a reduction in referrals to orthopaedics and rheumatology outpatient departments. However, it can result in an increase in use of physiotherapy services.     

Does providing more accessible primary care psychology services lower the clinical threshold for referrals?

BACKGROUND: The growing number of specialist services being provided within primary care has lead to the argument that this will reduce the clinical threshold for referrals to these clinics. AIM: The possibility that increasing the accessibility of primary care psychology services will reduce the threshold for referral was examined by comparing levels of psychological disturbance among patients seen by practice-based clinical psychologists with those attending outpatient clinics. METHOD: Psychological symptoms, distress, disruption in daily life and satisfaction with life were assessed using a questionnaire-based methodology. A consecutive series of 177 patients, assessed in a local general practice or an outpatient department across a wide range of urban locations, was studied over a fixed period. RESULTS: The study revealed equivalent levels of psychopathology within both specialist and primary care clinics. Of the overall sample, 79% were likely to merit a formal psychiatric diagnosis, relating primarily to mood disorder. Levels of subjective distress and life satisfaction were also equivalent at both service locations. CONCLUSION: The lack of evidence for a reduction in clinical threshold for referral within the primary care sample suggests that general practitioners' referral rates are similar regardless of whether practice-based clinical psychology services are available. This has implications for primary-care-led commissioning of mental health services.     

Mobile information and communication in the hospital outpatient service

OBJECTIVES: Most healthcare providers provide mobile service for their medical staff; however, few healthcare providers provide mobile service as part of their outpatient service. The mobile outpatient service system (MOSS) focuses on illness treatment, illness prevention and patient relation management for outpatient service users. Initiated in a local hospital in Taiwan, the MOSS pilot project was developed to improve outpatient service quality and pursue higher patient safety. METHOD: This study focuses on the development of the MOSS. The workflow, architecture and target users of the MOSS are delineated. In addition, there were two surveys conducted as part of this study. After a focus group of medical staff identified areas in which outpatient services might be improved by the MOSS, the first survey was administered to outpatients to confirm the focus group's intuitions. The second administration of the survey explored outpatient satisfaction after they used the MOSS service. RESULTS: With regard to outpatient attitudes, about 93% of participants agreed that the mobile outpatient service improved outpatient service quality. In the area of outpatient satisfaction, about 89% of participants indicated they were satisfied with the mobile outpatient service. DISCUSSION/CONCLUSION: Supported by our study finding, we propose that more diverse mobile outpatient services can be provided in the future.     

Psychological practice in a pediatric rehabilitation hospital

Described 127 consecutive referrals to a newly formed psychological consultation service in a pediatric rehabilitation hospital. This setting served children whose needs for comprehensive care and long-term hospitalization could not be met effectively elsewhere in the community. The complex patient population included children with permanent mental and/or physical handicaps who had survived due to advances in medical technology, those with traumatic or congenital brain injury, failure to thrive, feeding problems, apnea, tracheostomy, child abuse, and psychosomatic disorders. A range of psychological services were offered, including specialized assessments and treatment planning for rehabilitation, home and school placement, direct treatment and monitoring of behavioral progress, and consultation with staff. Implications for the practice of pediatric psychology and service delivery to patients in pediatric rehabilitation settings are discussed.     

Pediatric pain: prevalence,assessment, and management in a teaching hospital

The goal of this study was to examine the prevalence, assessment and management of pediatric pain in a public teaching hospital. The study sample consisted of 121 inpatients (70 infants, 36 children, and 15 adolescents), their families, 40 physicians, and 43 nurses. All participants were interviewed except infants and children who could not communicate due to their clinical status. The interview included open-ended questions concerning the inpatients'' pain symptoms during the 24 h preceding data collection, as well as pain assessment and pharmacological/non-pharmacological management of pain. The data were obtained from 100% of the eligible inpatients. Thirty-four children/adolescents (28%) answered the questionnaire and for the other 72% (unable to communicate), the family/health professional caregivers reported pain. Among these 34 persons, 20 children/adolescents reported pain, 68% of whom reported that they received pharmacological intervention for pain relief. Eighty-two family caregivers were available on the day of data collection. Of these, 40 family caregivers (49%) had observed their child''s pain response. In addition, 74% reported that the inpatients received pharmacological management. Physicians reported that only 38% of the inpatients exhibited pain signs, which were predominantly acute pain detected during clinical procedures. They reported that 66% of patients received pharmacological intervention. The nurses reported pain signs in 50% of the inpatients, which were detected during clinical procedures. The nurses reported that pain was managed in 78% of inpatients by using pharmacological and/or non-pharmacological interventions. The findings provide evidence of the high prevalence of pain in pediatric inpatients and the under-recognition of pain by health professionals.     

An integrated model for inner-city health-care delivery: the Deaconess Center.

Under the auspices of the Buffalo General Hospital and the faculty of medicine of the State University of New York at Buffalo, a comprehensive delivery system for primary care has been established in a local inner-city neighborhood. At the Deaconess Family Medicine Center, located within an inner-city location of Buffalo, New York, several divisions have been integrated to provide comprehensive patient-oriented primary care. These divisions include a primary care clinic, an urgent care clinic, a substance abuse clinic, and a community pediatrics clinic. Professional services are provided by attending physicians and residents. The horizontal integration of these four divisions is in turn vertically integrated with the tertiary care teaching hospital inpatient and obstetrical services, providing a continuum of patient care. The horizontal integration serves as an entry point for patients to enter the hospital''s health-care system, while the vertical integration capability serves to capture any specialized referrals or inpatient needs. This article discusses the structure of the center, with special reference to service integration, service delivery, and patient capture; medical education; and the place of integrated units in the strategic plan of a tertiary care hospital.     

Ambulatory paediatrics: does it work?

To determine whether a paediatric ambulatory assessment service is an effective and acceptable replacement for an inpatient unit. Analysis of hospital paediatric medical admissions. Postal questionnaire survey of local general practitioners. Telephone survey of parents of children who had attended the ambulatory service. Rural General Hospital in Northern Ireland. General practitioners. Parents of children referred to assessment service. Number of paediatric medical hospital admissions from the local area before and after the introduction of an ambulatory assessment service. General practitioner satisfaction levels. Parental satisfaction levels. Since the introduction of the new service in April 1996 there has been a marked progressive reduction in paediatric medical hospital admissions from the local area. By the third year of operation of the ambulatory service (1998/99), a 47% reduction in admissions was recorded, compared to the 1995/96 baseline year. The response rate to the general practitioner questionnaire was 65% (37 of 57) of whom most (31, 84%) found the service beneficial. Of the 37 respondents, 31 had referred patients to the service. The majority of these general practitioners (30, 97%) reported that the service was easy to access, and the same proportion felt that requests for consultation were met promptly. Most felt that feedback was appropriate (29, 94%). A telephone survey of 50 parents showed that most were either very satisfied (38, 76%), or satisfied (11, 22%) with the service. Most parents (41, 82%) felt their child had benefited by not being admitted to hospital. Most (46, 92%) felt they had received adequate information regarding their child's illness. A paediatric ambulatory assessment unit can reduce the number of children admitted to hospital and meet the needs of children, their families and general practitioners.     

高等教育社会服务认同状况调查

目的本文通过具体分析评价唐山高等教育直接满足本地社会现实需要的充分程度,探寻高等教育进一步提高社会服务绩效水平的途径。方法通过问卷调查,统计分析与综合分析所得数据。结果 1高校学科专业品质服务绩效认同度达到82.1%,具备社会化服务需要的学科专业;2高校服务社会的科研实力满意度仅为42.4%,需要提高社会服务的科研实力;3高校人才培养满意度为54.7%,要进一步重视并加强提高人才培养质量;4高校教师社会服务观念满意度达到54%,具备社会化服务观念;5高校已经建立社会化服务绩效评价机制的认同度低于40%,普遍缺乏社会化服务绩效评价机制。结论以更加科学的学科专业、更强的科研实力、更加全面、良好的人才,全面提高高等教育服务社会的效益,构建社会化服务绩效评价指标体系,科学管理和适时监控社会服务绩效。     

Organization of management of and role of clinical prognosis in the childhood oncological service of Russia]

Cancer control service cannot be managed without having a clear idea of trends and changes in the incidence of malignant neoplasms and associated death rates. These studies become a basis for setting up oncological facilities for both children and adults, having an adequate infrastructure (final fund, the profile of units, a list of staff, the volume of work). Pediatric oncological rooms to collect statistics, to make a primary diagnosis, a follow-up, and outpatient chemotherapy in children with malignant neoplasms, and to do methological work with pediatric and non-oncological specialized children's out- and inpatient units have been opened in most administrative, regional, territorial, and republican centers. Notification is much more complete where specialized pediatric oncological rooms (Moscow) register such children. Unfortunately, such rooms are still few and so such ill children are registered by regional and city oncological dispensaries (and, as shown, 50% of the patients are outside registration).     

The impact of acute urological admissions on the surgical workload in a general hospital

Urological services remain underdeveloped in the existing Irish Hospital network. Outside of the main teaching centres patients frequently present to their local hospital with acute urological problems and are referred to specialist units following preliminary investigations. Over six months we examined the impact of emergency urological presentations on the general surgical workload in an acute general hospital. A total of 54 of patients were admitted with urological presentations representing 6.7% of total surgical admissions. The average length of stay was 4.9 days and a total of 24.5% were transferred to urological units for inpatient treatment. Urology outpatient referrals were required for 40%. This paper illustrates the impact of urological admissions on peripheral hospitals and the need to expand urological services in regional hospitals to reduce the amount of patients transferred to tertiary centres for routine urological procedures.     

Conducting ‘development research’ in the new NHS: an illustration from two forms of inpatient care for those with severe mental illness

The NHS Research and Development Strategy has provided fresh impetus to the traditional interest of mental health practitioners in the evaluation and development of their services. The purpose of the present analysis is to outline a comparative evaluation of two kinds of service for people with enduring mental illness so as to highlight methods that can be used to develop services in keeping with the R & D strategy. Particular attention is given to the instruments that can be used to provide topical, reliable and valid indications of the relative benefits of different services. The illustrative evaluation was based on a sample of 47 service users attending either a traditional inpatient psychiatric hospital ward or a new inpatient unit, based in the community. Measures of these users' stress, coping and strain were recorded before and after up to 3-month periods of care, in addition to information on staff perspectives, client satisfaction and other variables. Statistical analyses indicated the slight superiority of the community-based service, but the lack of a rigorous research design precludes causal inferences. Rather, the study aims to draw out some technical and interpersonal lessons for service developers, in the context of an increasingly ‘effectiveness’-conscious NHS. © 1997 John Wiley & Sons, Ltd.     

Health facilities at the district level in Indonesia

Background

At Independence the Government of Indonesia inherited a weak and unevenly distributed health system to which much of the population had only limited access. In response, the government decided to increase the number of facilities and to locate them closer to the people. To staff these health facilities the government introduced obligatory government service for all new graduates in medicine, nursing and midwifery. Most of these staff also established private practices in the areas in which they were located. The health information system contains little information on the health care facilities established for private practice by these staff. This article reports on the results of enumerating all health facilities in 15 districts in Java.

Methods

We enumerated all healthcare facilities, public and private, by type in each of 15 districts in Java.

Results

The enumeration showed a much higher number of healthcare facilities in each district than is shown in most reports and in the health information system which concentrates on public, multi-provider facilities. Across the 15 districts: 86% of facilities were solo-provider facilities for outpatient services; 13% were multi-provider facilities for outpatient services; and 1% were multi-provider facilities offering both outpatient and inpatient services.

Conclusion

The relatively good distribution of health facilities in Indonesia was achieved through establishing public health centers at the sub-district level and staffing them through a system of compulsory service for doctors, nurses and midwives. Subsequently, these public sector staff also established solo-provider facilities for their own private practice; these solo-provider facilities, of which those for nurses are almost half, comprise the largest category of outpatient care facilities, most are not included in official statistics. Now that Indonesia no longer has mandatory service for newly graduated doctors, nurses and midwives, it will have difficulty maintaining the distribution of facilities and providers established through the 1980s. The current challenge is to envision a new health system that responds to the changing disease patterns as well as the changes in distribution of health facilities.

     

What do medicine clerkship preceptors do best?

PURPOSE: Students' ratings of preceptors are widely used in medical education for feedback and evaluation purposes. The present study investigated students' ratings of the clinical teaching skills of inpatient attending physicians, inpatient residents, and outpatient attending physicians to assess differences among types of preceptors and relative strengths and weaknesses. METHOD: A total of 268 students from three academic years (1997-2000) at one medical school rated preceptors on an end-of-clerkship evaluation, for a total of 1,680 ratings. When the ratings were aggregated by preceptors' names and types, there were 691 mean ratings of preceptors. Relative strengths and weaknesses were identified. Differences in mean ratings by preceptor type (inpatient attending physician, inpatient resident, and outpatient attending physician) were evaluated, and strengths and weaknesses were identified by rank ordering the items' means. RESULTS: Students tended to rate outpatient attending physicians higher than inpatient attending physicians or residents. Areas where ratings suggested relative strengths included showing an interest in teaching, respecting students' opinions, and being available to students. Areas of relative weakness included increasing physical examination and interviewing skills. CONCLUSIONS: Students' ratings are useful for identifying strengths and weakness for groups of preceptors and, as such, are important sources of information for setting priorities for faculty development efforts.     

Follow-up results from a psychosomatic outpatient clinic

On the background of the German situation of psychosomatic medicine as an independent department beside the psychiatric clinic, we describe the theoretical issues, organizational structure and functioning of a psychosomatic outpatient clinic. 186 consecutive referrals were analyzed. The ratio of man to woman was 1:2, mean age was 32 years (range 17-58). About half of the patients suffered from psychogenic disorders (according DSM-III criteria subsumed to the category of 'psychological factors affecting physical condition'), 21% had anxiety disturbances, and of the remaining patients 15% had affective illnesses and 13% somatoform disorders. There were three treatment conditions: inpatient psychotherapy, outpatient individual or group psychotherapy and family therapy. Follow-up results (2 years after the first contact) give some hints on the effectiveness of the different treatment procedures. The results show that the psychosomatic outpatient clinic may offer treatment for a specific patient population whose characteristics differ significantly from those of patients treated in consultation liaison services as well as by practicing psychotherapists.     

Consumer contribution to the delivery of genetic health services

Clinical genetics services have been the focus of evaluation and guidelines since the 1970s. In this study we used consumer satisfaction as the evaluative measure with the aim being to seek feedback from consumers of a genetics service to inform quality measures for client-centered genetic services. In the first phase of the study issues were identified by consumers and health professionals around delivering genetics services and the priorities ranked into five themes: expectations, information, respect, privacy and logistics. These themes then formed the basis of a questionnaire that was distributed to consumers of a genetics service in Victoria, Australia. Three hundred ninety-seven out of 821 questionnaires were completed (49.8% response rate). More than 85% of consumers were satisfied in the theme of expectations, with the only issue being waiting times for genetic test results (68.6% satisfied). Over 83% of consumers were satisfied with the information received from the genetics service. The matter of interruptions during appointments was the only area in the theme of respect that rated less than 80% satisfactory (79.1%). In relation to privacy, consumers rated over 95% satisfaction. Logistics was the theme where satisfaction was lowest with ratings of less than 75% for issues such as availability of public transport to the clinic, parking and wheelchair access. Consumer satisfaction was related to the information received before and after consultations and also to the attitudes and behaviors of health professionals. These findings have implications for genetics services both in Australia and internationally and recommendations from the findings are outlined.     

Comparing satisfaction levels of inpatients and outpatients with a diabetes teaching program.

With the changing climate of health care there is an increasing need to offer diabetes education in outpatient rather than inpatient settings. This study was conducted to determine if there is a significant difference in the satisfaction level between inpatients and outpatients receiving diabetes teaching in the same program. Patient satisfaction with the practitioner is a determinant of patient learning and compliance. The study included 42 inpatients and 47 outpatients who participated in the same program and were taught by the same teaching nurses and dietitians. A questionnaire developed for this study examined six areas: (1) demographics; (2) patients' perception of understanding their diabetic condition and treatment; (3) comfort in class; (4) perception regarding treatment as an individual; (5) life satisfaction; and (6) influence of recommendations on future health. The results of the study showed a significant difference (P less than 0.05) in two areas: (1) inpatients felt that more interest and concern were shown towards them than outpatients and (2) more inpatients than outpatients felt they were treated more like individuals than cases. The results indicated that the personalized and ongoing contact inpatients have with the practitioner determine the degree of satisfaction with diabetes teaching received in these important areas.     

Physician gender,physician patient-centered behavior,and patient satisfaction: A study in three practice settings within a hospital

Objective

To compare male and female physicians on patient-centeredness and patients’ satisfaction in three practice settings within a hospital; to test whether satisfaction is more strongly predicted by patient-centeredness in male than female physicians.

Methods

Encounters between physicians (N = 71) and patients (N = 497) in a hospital were videotaped and patients’ satisfaction was measured. Patient-centeredness was measured by trained coders.

Results

In the outpatient setting, female physicians were somewhat more patient-centered than male physicians; patient satisfaction did not differ. In the inpatient and emergency room settings, female physicians were notably more patient-centered than male physicians; satisfaction paralleled these differences. Nevertheless, there was some, though mixed, evidence that patient-centeredness predicted satisfaction more strongly in male than female physicians, suggesting that patients valued patient-centered behavior more in male than female physicians.

Conclusion

Even though satisfaction mirrored the different behavior styles of male and female physicians in the inpatient and emergency room settings, in all settings male physicians got somewhat more credit for being patient-centered than female physicians did.

Practice implications

If female physicians do not consistently receive credit for high patient-centeredness in the eyes of patients, this could lead female physicians to reduce their patient-centered behavior.