Do better quality consultations result in better health? Relationship between quality of consultations and health status of patients with non-acute abdominal complaints in general practice

BACKGROUND: In theory, a positive relationship is expected between the quality of a consultation and a patient's subsequent health status. However, such a relationship has not yet been firmly established in daily practice. OBJECTIVE: We aimed to study the relationship between the quality of the first consultation in a new episode of non-acute abdominal complaints and subsequent health status of patients in general practice. METHODS: Quality scores for 743 consultations were calculated on the basis of review criteria developed by expert panels. Functional health status was measured by the SIP (Sickness Impact Profile) at baseline, and at 1 and 6 months after the consultation. Multilevel regression analysis was used to examine the relationship between the quality of consultations and health status, and to identify factors of influence on this relationship. RESULTS: In the majority of these patients (97%) health status improved regardless of consultation quality. In patients with malignant disease, and chronic colitis, however, an association between consultation quality and subsequent health status was found: in those with a high consultation quality score (>66-percentile) the health status deteriorated in the first month but improved over the following 5 months; in those with a low consultation quality score (<33-percentile) it deteriorated continuously. CONCLUSION: For the great majority of patients we found no relation between the quality of consultation and health status. However, for a very small subgroup of patients there is proof of benefit from better quality consultations.     

How do we know if we are making a difference with our program or community initiative?

In this article, the authors discuss issues related to knowing if health workers are making a difference with their community initiatives or programs being delivered in a community setting. Issues relating to the choice of evaluation questions, relevance of data sets used to answer those questions, and the rigor by which the answer can be evaluated--and the ability to generalize to other communities or populations--are explored. Finally, relevant resources to help you pursue these issues are provided.     

Clinical inquiries. How does tissue adhesive compare with suturing for superficial lacerations?

Tissue adhesives are effective and yield results comparable to those with conventional suturing of superficial, linear, and low-tension lacerations. The cosmetic outcome is similar; wound complications, such as infection and dehiscence, may be lower with tissue adhesives. Wound closure of superficial lacerations by tissue adhesives is quicker and less painful compared with conventional suturing (strength of recommendation: A, systematic reviews of randomized trials).     

Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?

BACKGROUND: Clinical questions frequently arise during the practice of medicine, and primary care physicians frequently use curbside consultations with specialty physicians to answer these questions. It is hypothesized that well-formulated clinical questions are more likely to be answered and less likely to receive a recommendation for formal consultation. OBJECTIVE: To assess the relationship between the structure of clinical questions asked by family physicians and the response of specialty physicians engaged in curbside consultations. DESIGN AND PARTICIPANTS: A case series of clinical questions asked during informal consultations between 60 primary care and 33 specialty physicians using an e-mail service. Curbside consultation questions were sent, using e-mail, to academic specialty physicians by primary care physicians (faculty, residents, and community practitioners) in eastern Iowa. MAIN OUTCOME MEASURES: Questions were analyzed to determine the clinical task and to identify 3 components: an intervention, a comparison, and an outcome. Consultants' responses were analyzed to identify whether questions were answered and whether consultants recommended formal consultation. RESULTS: There were 708 questions in this analysis: 278 (39.3%) were diagnosis questions, 334 (47.2%) were management questions, 57 (8.0%) were prognosis questions, and 39 (5.5%) were requests for direction. Clinical questions were less likely to go unanswered or receive a recommendation for formal consultation when the question identified the proposed intervention (odds ratio, 0.54; 95% confidence interval, 0.34-0.86; P = .006) and desired outcome (odds ratio, 0.46; 95% confidence interval, 0.29-0.69; P < .001). Only 271 (38.3%) of 708 curbside consult questions identified both of these components. CONCLUSION: Medical specialists' responses to curbside consultation questions seem to be affected by the structure of these clinical questions.     

How do general practitioners assess the criteria for due care for euthanasia in concrete cases?

OBJECTIVE: In the Netherlands the law states that physicians are allowed to grant a request for euthanasia or physician-assisted suicide (EAS) if specific criteria for due care are met. This study investigated which sources physicians use to determine whether three of these criteria (unbearable and hopeless suffering, and no realistic alternatives for treatment) are met. METHODS: The data were collected for the project Support and Consultation on Euthanasia in the Netherlands. General practitioners (GPs) received a written questionnaire concerning the most recent request for EAS that they had received. Of the 3614 (60%) GPs who returned the questionnaire, 1681 described the most recent request for EAS. RESULTS: The study shows that physicians used different types of sources, and more than one source, to determine whether the criteria were met. More sources were used when the criteria were met or when a request resulted in EAS. The determination of every criterion required a different approach, but for all criteria discussions with colleagues were important. CONCLUSIONS: Using less sources when a criterion is not met could possibly lead to less extensive consideration of the criteria, and therefore to assessing too easily that the request does not meet the criteria for due care.     

Did adolescents in Norway respond to the elimination of copayments for general practitioner services?

Copayments for primary care services may lead to decreased access to and underconsumption of necessary health care for vulnerable patient groups, such as adolescents. In Norway, in 2010, adolescents aged 12 to 15 years were exempted from copayments for general practitioner (GP) services, and the aim of this study is to estimate whether being exempted from copayments led to increases in GP visits. We apply the synthetic control method using the elastic net regression as a data‐driven approach to construct a relevant counterfactual from our pool of age groups not affected by the reform. Data on the number of GP consultations for males and females from 2006 to 2013 is obtained from the Norwegian Health Economics Administration. Our findings suggest that exempting adolescents from copayments increased the number of per person GP consultations by 22.1% among females and 13.8% among males. This indicates that adolescents between the ages of 12 and 15 were sensitive to copayments before the reform and females more so than males.     

How do NHS general hospitals in England deal with patients with alcohol-related problems? A questionnaire survey

AIMS: Alcohol-related disease represents a major burden on hospitals. However, it is unclear whether hospitals have developed the necessary expertise and guidelines to deal with this burden. The aim of this survey was to determine what measures general hospital NHS Trusts in England had in place to deal with alcohol-related problems, including the employment of dedicated alcohol specialist nurses. METHODS: Two postal surveys of all NHS general hospital Trusts in England, the first in 2000 (n = 138; 54% response rate) and the second in 2003 after the publication of the Royal College of Physicians (RCP) report on alcohol in secondary care (n = 164; 75% response rate). RESULTS: Between the two surveys, there was a significant increase (P = 0.005) in the number of dedicated alcohol nurses employed by general hospital trusts; however, the numbers remain low (n = 21). Additionally, the availability of prescribing guidelines for the management of alcohol withdrawal increased significantly (P = 0.0001). CONCLUSIONS: The survey indicates that most general hospitals do not have appropriate services in place to deal with such patients. Although there is a need and willingness to develop alcohol services in general hospitals, which is one of the key recommendations of the RCP report, the lack of funding is going to act as a major barrier.     

Models of service support for parents of disabled children. What do we know? What do we need to know?

Research carried out over a number of years provides a consistent picture of the experiences and needs of parents of disabled children. Recent studies, based on models of stress and coping, have identified factors which relate to high or low levels of parental distress. Whilst this research can provide useful information for service development, there appears to have been little change over the years in parents' reports of unmet need. It is clear that parental need covers a wide range of aspects of family life and holistic models of service support are required. Although evaluation studies which identify models of services that can change this situation are few, there are positive examples of models of support. The paper reviews the findings of such evaluation and identifies a number of important characteristics of effective service models.     

How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions

Maintaining patient safety in acute hospitals is a global health challenge. Traditionally, patient safety measures have been concentrated on critical care and surgical patients. In this review the medical literature was reviewed over the last ten years on aspects of patient safety specifically related to patients with dementia. Patients with dementia do badly in hospital with frequent adverse events resulting in the geriatric syndromes of falls, delirium and loss of function with increased length of stay and increased mortality. Contributory factors include inadequate assessment and treatment, inappropriate intervention, discrimination, low staff levels and lack of staff training. Unfortunately there is no one simple solution to this problem, but what is needed is a multifactorial, multilevel approach at the seven levels of care – patient, task, staff, team, environment, organisation and institution.Improving safety and quality of care for patients with dementia in acute hospitals will benefit all patients and is an urgent priority for the NHS.     

The needs of patients with rare disease in Serbia. Why do we need National Strategy for rare disease?

The patients with rare diseases in Serbia face the difficulties in procurement of medications as the Health insurance fund does not cover reimbursement for some medications, they face difficulties in receiving proper diagnosis which makes their position specific and complex. In an attempt to provide more support for the patients with rare diseases, their families and caregivers the helpline for rare diseases was established in October 2015. The aim of this research was to identify, examine and systematise needs of helpline users and forms of assistance provided by the team from the free helpline. The research was designed as a cross‐sectional study and was conducted between October 2015 and December 2016. The electronic database of National Organization for rare disease in Serbia helpline users was used as a data source. The user was the person who contacted helpline (patient, relative, friend, physician, etc). The “need” refers to the reasons for addressing the helpline. Helpline users had 549 needs in total; about healthcare—236 (42.98%), social care—113 (20.58%), psychological support—56 (10.20%) and other—144 (26.22%). Services were provided by the lawyer—130 (23.70%), social worker—71 (12.93%), Psychologist—56 (10.20%) and by all employees—292 (53.19%). The most common need for legal assistance among needs on healthcare was on legal aspects of access to and reimbursement of expenses for medications (32/74%–43.24%) and procedures for reimbursement of treatment abroad (11/74%–14.86%). The problems of patients with rare diseases and their families result primarily from the lack of relevant information and knowledge, as well as the non‐recognition of rare diseases in the laws and regulations of health and social care. Some problems can simply be solved by legal changes and by a better organisation and do not require additional funding. Only by adopting and implementing the National Strategy and Action Plan for Rare Diseases, the greatest number of problems and needs of people with rare diseases can be systematised and solved.     

Microepidemics of tuberculosis in schools. How should we select contacts?

BACKGROUND: Outbreaks of microepidemics of tuberculosis indicate the existence of Mycobacterium tuberculosis transmission. We describe a microepidemic in a school in which an index case with low infective capacity gave rise to a high percentage of tuberculosis infection and disease in the center. METHODS: Contact investigation was performed in 423 pupils of a school after a recently arrived teacher with few symptoms was diagnosed with tuberculosis. A cross-sectional study was carried out to calculate the prevalence of tuberculosis infection and disease in the school center. RESULTS: Statistically significant differences were found in the distribution of positive results in the first tuberculosis skin test for primary and secondary students, with more positive results in secondary school pupils (18.4%) than in primary school pupils (6.1%). The incidence of skin tuberculosis test converters was 5.7%. The prevalence of infection by educational level was 10% in primary education and 23.4% in secondary education. The risk of infection in secondary school pupils was more than twice that in primary school pupils (OR = 2.4; 95% CI, 1.5-3.5). There were 6 new cases of tuberculosis in pupils. CONCLUSION: The high percentage of conversions in the second tuberculosis skin test indicated the existence of transmission in the school. The results of this study support contact investigation in schools where there is exposure to a case of tuberculosis, whether highly infective or nort.