Quality of care in teaching hospitals: a literature review.

PURPOSE: To compare the quality of care in teaching hospitals with that in nonteaching hospitals. METHOD: By performing a literature review via PubMed, the author identified and surveyed 23 studies that compared the quality of care in teaching hospitals with that in nonteaching hospitals. The studies were published from 1989-2004 and in all but one case dealt exclusively with U.S. hospitals. RESULTS: The teaching hospitals studied had better-quality measures than did nonteaching hospitals in the predominant number of studies reviewed. Process measures were significantly better in teaching hospitals in seven of the eight studies where such measures were observed, and equal in the other study. Risk-adjusted mortality was lower in teaching hospitals in nine of the 15 studies using that measure, not significantly different in five, and significantly lower in nonteaching hospitals in one study (in pediatric intensive care units, even though the teaching hospitals had a better process of care). In nonmortality outcomes, teaching hospitals were better in one study using that measure; there were no significant differences in five other such studies. Major teaching hospitals had more favorable outcomes end points than did minor teaching hospitals in eight studies in which they were compared. Including only those six studies using clinical data for process analysis or risk adjustment, teaching hospitals had a better process in all six and lower adjusted mortality in five of seven studies where that measure was used. CONCLUSIONS: Overall, the favorable results in teaching hospitals extended over a range of locations, conditions, and populations, including routine as well as complex conditions. However, the quality measured in these studies was not at target levels across the spectrum of hospitals. There needs to be a continuous and determined effort for improvement in all institutions. It is to be hoped that teaching hospitals will take the lead not only in continuously improving their own quality, but also in developing and evaluating ever improving methods of quality assessment.     

Assessing quality and costs of education in the ambulatory setting: a review of the literature.

PURPOSE: Time-pressured interactions with little direct observation or feedback characterize teaching in ambulatory settings. The authors report findings from the literature on teaching and learning in the ambulatory setting and propose opportunities for further research that addresses these barriers. METHOD: The authors searched 1995-1999 databases for all empirical studies that focused on research conducted in ambulatory settings. Publications were reviewed for evidence of inclusion criteria. Findings were sorted into categories previously described for defining and evaluating quality of ambulatory care educational programs. RESULTS: Most studies were conducted in departments of internal medicine (40%), focused on medical students (43%), and took place in a single program (77%), making generalizations difficult. Students and residents are learning in ambulatory environments, and the types of patients they encounter are likely to prepare them for practice. Patient care outcomes have emerged as a measure of learning. Teachers may be the single most important factor, yet they lack self-confidence as teachers. Community-based preceptors teach because of enjoyment of teaching and the opportunity to stay current. However, none of the studies addressed the impact of the Medicare documentation requirements on satisfaction with teaching. Teaching settings cost about one third more than non-teaching settings to operate. CONCLUSION: This review identifies many gaps in our knowledge of effective clinical teaching practices, and of learning environments in which that teaching takes place. The predominance of single-institution studies limits generalizability of current findings. A prioritized research agenda should be established and funded, focusing on improving the efficiency and effectiveness of teaching and learning in ambulatory settings.     

Walk-in centres in primary care: a review of the international literature.

Nurse-led walk-in centres were first announced in April 1999. They represent a new development in unscheduled care provision in the United Kingdom (UK) National Health Service (NHS). By the end of 2000, 40 NHS walk-in centres had been opened, with further centres recently announced. This paper aims to review international experience with walk-in centres in primary and emergency care and identify relevant lessons for the UK. This study is a systematic review, with qualitative synthesis of relevant findings. Studies were identified from seven major bibliographic databases using a sensitive search strategy, and 244 relevant documents relating to walk-in or 'ambulatory care' centres were identified. Users of walk-in centres in other countries tend to be a relatively affluent population of working age, and a different population from those using conventional general practice services. Walk-in centres are used particularly when other health services are closed. The problems presented are mainly minor illnesses and minor injuries. People choose this form of care mainly for reasons of convenience, and satisfaction with the service is generally high. The very limited evidence available suggests that walk-in centres provide care of reasonable quality, but there is insufficient evidence to draw firm conclusions about the impact of walk-in centres on other healthcare services or the costs of such care. Although a number of countries have had a long experience of walk-in centres, the lack of reliable evidence on many of the most important issues is notable. In the NHS, walk-in centres represent a radically innovative attempt to improve access to health care, but the limited research available does little to inform their development. Important questions that need to be addressed include whether walk-in centres do improve access to care, for whom, and at what overall cost.     

Overview of recent literature on undergraduate ambulatory care education and a framework for future planning.

This study provides an interpretive overview of ambulatory care undergraduate education from 1979 to 1991 and identifies two major problems for medical education: (1) the difficulties inherent in the transfer of educational techniques from the hospital to the ambulatory care setting; and (2) the misuse of and lack of agreement on definitions of ambulatory care, primary care, and community-oriented primary care. The authors distinguish various types of ambulatory care and examine factors that differentiate ambulatory care and hospital sites for educating medical students, including the setting, program management, curriculum issues, evaluation, cost, faculty time, and space. Based on concepts and issues identified in the study, the authors propose a framework for planning future ambulatory care education and research.     

Physicians' responses to financial incentives. Evidence from a for-profit ambulatory care center

Health Stop is a major chain of ambulatory care centers operating for profit. Until 1985 its physicians were paid a flat hourly wage. In the middle of that year, a new compensation plan was instituted to provide doctors with financial incentives to increase revenues. Physicians could earn bonuses the size of which depended on the gross incomes they generated individually. We compared the practice patterns of 15 doctors, each employed full time at a different Health Stop center in the Boston area, in the same winter months before and after the start of the new arrangement. During the periods compared, the physicians increased the number of laboratory tests performed per patient visit by 23 percent and the number of x-ray films per visit by 16 percent. The total charges per month, adjusted for inflation, grew 20 percent, mostly as a result of a 12 percent increase in the average number of patient visits per month. The wages of the seven physicians who regularly earned the bonus rose 19 percent. We conclude that substantial monetary incentives based on individual performance may induce a group of physicians to increase the intensity of their practice, even though not all of them benefit from the incentives.     

Triadic communication in the primary care paediatric consultation: a review of the literature.

BACKGROUND: Children aged 6-12 years are usually seen in primary care with an adult carer. It is a government and professional priority for doctors to try and involve these children in their medical consultations. AIM: To ascertain the evidence available on the amount and type of involvement that children in the 6-12 year age group have in their primary care consultations when the consultation was held with a child, a GP, and an adult. DESIGN OF THE STUDY: Literature review. METHOD: Data sources included MEDLINE, CINAHL, EMBASE, and ERIC, The Cochrane library, PsychINFO, Web of Science and Wilson's Social Science abstracts, hand searching for references, and contact with authors. RESULTS: Twenty-one studies were selected for inclusion in the study. Children were found to have little quantitative involvement in their own consultations. They may take part during information gathering but are unlikely to participate in the treatment planning and discussion parts of the consultation. CONCLUSION: Children in the 6-12 year age group have little meaningful involvement in their consultations.     

Leukoedema: a review of the literature.

Leukoedema, a grayish-white lesion of the oral mucosa in humans, was once thought to be a probable precursor to leukoplakia. Clinical examination differentiates leukoedema from leukoplakia, lichen planus, white sponge nevus, and pathomimia morsicatio buccarum. Prevalence rates vary greatly in different countries and in different ethnic groups. For many years, leukoedema was alleged to occur only in adult populations until Martin and Crump found this lesion in children and youth. There is a definite predilection for this lesion in black Americans. Although the etiology is unknown, it has been suggested that leukoedema develops in areas of local irritation. This article reviews the literature related to the prevalence of leukoedema and correlates the independent findings, which might pertain to its etiology.     

Bereavement care in primary care: a systematic literature review and narrative synthesis

Background

Over half a million people die in Britain each year and, on average, a GP will have 20 patients die annually. Bereavement is associated with significant morbidity and mortality, but the research evidence on which GPs and district nurses can base their practice is limited.

Aim

To review the existing literature concerning how GPs and district nurses think they should care for patients who are bereaved and how they do care for them.

Design

Systematic literature review.

Method

Searches of AMED, BNI, CINAHL, EMBASE, Medline and PsychInfo databases were undertaken, with citation searches of key papers and hand searches of two journals. Inclusion criteria were studies containing empirical data relating to adult bereavement care provided by GPs and district nurses. Information from data extraction forms were analysed using NVivo software, with a narrative synthesis of emergent themes.

Results

Eleven papers relating to GPs and two relating to district nurses were included. Both groups viewed bereavement care as an important and satisfying part of their work, for which they had received little training. They were anxious not to ‘medicalise’ normal grief. Home visits, telephone consultations, and condolence letters were all used in their support of bereaved people.

Conclusion

A small number of studies were identified, most of which were >10 years old, from single GP practices, or small in size and of limited quality. Although GPs and district nurses stated a preference to care for those who were bereaved in a proactive fashion, little is known of the extent to which this takes place in current practice, or the content of such care.     

Predicting costs of mental health care: a critical literature review

BACKGROUND: Cost evaluation research in the mental health field is being increasingly recognized as a way to achieve a more effective deployment of scarce resources. However, there is a paucity of studies that seek to identify predictors of psychiatric service utilization and costs. This paper aims to critically review the published research in the field of psychiatric service utilization and costs, and discusses current methodological developments in this field. METHOD: Sixteen studies were identified and are critically reviewed. RESULTS: No single variable alone can explain variations in costs between patients; instead, a range of different clinical and non-clinical variables provides a greater explanation of cost variations. Having a history of previous psychiatric service use is the most consistent predictor of higher psychiatric costs. Only one study considers indirect costs incurred by users, their families and friends and society as a whole, with the remaining 15 studies focusing on direct mental health care costs. There is a lack of studies that consider the future psychiatric service utilization and costs of care of children and older people. The cross-validation of predictive models is not yet routine, with only four of the studies including a cross-validation procedure. CONCLUSIONS: The predictive approach in mental health cost evaluation has relevance for both mental health policy and practice. However, there is a paucity of studies that focus on children, older people and indirect costs. Furthermore, there remain a number of methodological challenges to address.     

Evidence for handheld electronic medical records in improving care: a systematic review

Background  

Handheld electronic medical records are expected to improve physician performance and patient care. To confirm this, we performed a systematic review of the evidence assessing the effects of handheld electronic medical records on clinical care.     

Patient-centred consultations and outcomes in primary care: a review of the literature

Although 'patient-centred' consulting skills are increasingly seen as crucial for the delivery of effective primary care, there is significant lack of clarity over the precise definition of the term, optimal methods of measurement, and the relationship between patient-centred care and patient outcomes. The present study sought to review all empirical studies to date that have investigated the relationship between measures of patient-centred consulting and outcomes in primary care, and to examine the methodological rigour of the studies. A number of observational studies were identified, all of which reported some relationships between doctor behaviour defined as 'patient-centred' and a variety of patient health outcomes. However, the pattern of associations was not clear or consistent, and some of the studies had shortcomings in terms of their internal and external validity. Although the current evidence base may be suggestive of a relationship between patient-centred consulting behaviour and patient outcomes, the case has not been made definitively.     

Health care needs in end-stage COPD: a structured literature review

OBJECTIVE: To give an overview of relevant literature regarding health care needs in end-stage COPD and to identify specific areas where knowledge about needs is still lacking. METHODS: We conducted a structured literature review. We used Bradshaw's classification system. RESULTS: Seventy-seven publications were found. Ten publications were included in the review. The results reported cover a wide range of subjects, all regarded as health care needs. Most reported on 'felt need', i.e. needs that are mentioned by patients themselves. Results on 'normative need' (based on expert judgement) were lacking. CONCLUSION: The literature about the health care needs of patients in the end-stage of COPD is sparse, and there is no commonly accepted definition of health care needs. Looking at the increasing demand for end of life care for COPD patients, there is a clear need for further research on this subject. PRACTICE IMPLICATIONS: We especially need to focus on agreement between experts and professionals so that guidelines can be developed. To attend to the unfulfilled needs of end-stage COPD patients, the delivery of health care should be re-examined carefully.     

Evaluation of communication training programs in nursing care: a review of the literature

An important aspect of nursing care is communication with patients. Nurses' major communication tasks are not only to inform the patient about his/her disease and treatment, but also to create a therapeutically effective relationship by assessing patients' concerns, showing understanding, empathy, and providing comfort and support. In this review, 14 studies, which focus on the evaluation of the effects of communication training programs for nurses, have been evaluated. The selected studies were screened on several independent, process and outcome variables as described by Francke et al. [8]. In this way not only is the training program taken into account as a variable which may be responsible for nurses' behavioural change and for changes in patient outcomes, but also a range of other variables which can give more nuanced explanations for a training program's degree of effectiveness. On the whole, the studies reviewed showed limited or no effects on nurses' skills, on nurses' behavioural changes in practice, and on patient outcomes. Finally, the majority of the studies had a weak design. The use of experimental research designs should be pursued in future studies in order to eliminate the influence of confounding variables.     

Use of formal and informal care among people with prolonged fatigue: a review of the literature.

Prolonged fatigue is a common symptom in the community and a common complaint in GPs' surgeries. The current consensus is that prolonged fatigue is most appropriately managed within primary care but that quality of care is patchy. Diagnosis is difficult and there is no conclusive evidence about effective treatment. This can lead to confusion and controversy among lay people and health professionals alike. Although the value of a positive doctor-patient relationship is emphasized, general practice consultations are frequently experienced as difficult by both parties. Moreover, little is known about how people access other sources of care and information about prolonged fatigue, such as alternative medicine, self-help groups, lay others, and self care, in conjunction with or as an alternative to care from health professionals. This paper reviews the literature on the nature and extent of the problem prolonged fatigue represents for primary care, and on the use of formal and informal care for prolonged fatigue.     

Lactobacillus paracasei continuous ambulatory peritoneal dialysis-related peritonitis and review of the literature

We describe the first case of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis due to Lactobacillus paracasei. It occurred in a 65-year-old patient with recurrent episodes of peritonitis while he was receiving a prolonged course of intraperitoneal vancomycin. L. paracasei should be considered in the differential diagnosis of pathogens in CAPD-related peritonitis, especially in patients receiving prolonged vancomycin or glycopeptide treatment.     

Pregnancy during residency: a literature review.

PURPOSE: It is estimated that by 2010 30% of U.S. physicians will be women. Pregnancy during residency can and does happen in all programs, and continues to provide problems for many. The author reviews the issues surrounding pregnancy during residency by evaluating published commentaries and research reports. METHOD: A literature search was conducted using Medline (January 1984-October 2001). Published articles were categorized as research or commentary. Research reports were sorted by content and summarized under three headings: mother and infant health, sources of stress and support for the pregnant resident, and reactions of colleagues to the pregnant resident. RESULTS: A total of 27 research reports were located; two additional reports published before 1984 were added because they complemented included studies. The majority of the studies in this review used retrospective self-report questionnaires, mostly completed by female residents and physicians. All reports suggested an increased risk of complications, especially adverse late-pregnancy events, for pregnant physicians. Pregnant residents found the physical demands of residency and lack of support from fellow residents and their departments most stressful. Anger and resentment toward the pregnant resident were common among not-pregnant residents, feelings particularly associated with expectations of increased workload. Individual maternity/parental leave policies were inconsistent. Policy development is discussed. CONCLUSIONS: The studies in this review supported planning for residents' pregnancies, and the author advocates clear maternity/parental leave policies. The author comments on the use of existing data to make common sense changes and on the need for further studies to help clarify the issues and evaluate program changes.     

End of life care in sub-Saharan Africa: a systematic review of the qualitative literature

Background  

End of life (EoL) care in sub-Saharan Africa still lacks the sound evidence-base needed for the development of effective, appropriate service provision. It is essential to make evidence from all types of research available alongside clinical and health service data, to ensure that EoL care is ethical and culturally appropriate. This article aims to synthesize qualitative research on EoL care in sub-Saharan Africa to inform policy, practice and further research. It seeks to identify areas of existing research; describe findings specifically relevant to the African context; and, identify areas lacking evidence.     

Postnatal depression: a review of recent literature.

Depression affects 5-22% of women after childbirth. Some women with postnatal depression will experience a prolonged or relapsing illness that may last until their children enter school. It has adverse effects upon the coping abilities of women, their relationships with their infants, partners and social networks and may adversely affect the educational attainment and behaviour of their children. Since many more women are now active in the workforce, the effects of postnatal depression have obvious economic consequences both for their families and their employers. This article discusses the association between depression and the puerperium and reviews the evidence for vulnerability factors that may make a woman prone to depression. It is suggested that women with, or vulnerable to, postnatal depression can be identified and helped.