Improving access to specialist care for remote Aboriginal communities: evaluation of a specialist outreach service.

OBJECTIVE: To identify barriers faced by Aboriginal people from remote communities in the Northern Territory (NT) when accessing hospital-based specialist medical services, and to evaluate the impact of the Specialist Outreach Service (SOS) on these barriers. DESIGN: Combined quantitative and qualitative study. SETTING: Remote Aboriginal communities in the "Top End" of the NT, 1993-1999 (spanning the introduction of the SOS in 1997). PARTICIPANTS: 25 remote health practitioners, patients and SOS specialists. MAIN OUTCOME MEASURES: Numbers of consultations with specialists; average cost per consultation; perceived barriers to accessing hospital-based outpatient care; and perceived impact of specialist outreach on these barriers. RESULTS: Perceived barriers included geographic remoteness, poor doctor-patient communication, poverty, cultural differences, and the structure of the health service. Between 1993 and 1999, there were 5,184 SOS and non-SOS outreach consultations in surgical specialties. Intensive outreach practice (as in gynaecology and ophthalmology) increased total consultations by up to 441% and significantly reduced the number of transfers to hospital outpatient clinics (P< 0.001). Average cost per consultation was $277 for SOS consultations, compared with $450 at Royal Darwin Hospital and $357 at the closest regional hospital. Outreach has reduced barriers relating to distance, communication and cultural differences, and potentially bolsters existing primary healthcare services. CONCLUSIONS: When compared with hospital-based outpatient services alone, outreach is a more accessible, appropriate and efficient method of providing specialist medical services to remote Aboriginal communities in the NT.     

Aboriginal health workers and diabetes care in remote community health centres: a mixed method analysis

OBJECTIVE: To assess the effect of employing Aboriginal health workers (AHWs) on delivery of diabetes care in remote community health centres, and to identify barriers related to AHWs' involvement in diabetes and other chronic illness care. DESIGN, SETTING AND PARTICIPANTS: Three-year follow-up study of 137 Aboriginal people with type 2 diabetes in seven remote community health centres in the Northern Territory. MAIN OUTCOME MEASURES: Delivery of guideline-scheduled diabetes services; intermediate outcomes (glycated haemoglobin [HbA(1c)] and blood pressure levels); number and sex of AHWs at health centres over time; barriers to AHWs' involvement in chronic illness care. RESULTS: There was a positive relationship between the number of AHWs per 1000 residents and delivery of guideline-scheduled diabetes services (but not intermediate health outcomes). Presence of male AHWs was associated with higher adherence to the guidelines. Barriers to AHWs' involvement in chronic illness care included inadequate training, lack of clear role divisions, lack of stable relationships with non-Aboriginal staff, and high demands for acute care. CONCLUSIONS: Employing AHWs is independently associated with improved diabetes care in remote communities. AHWs have potentially important roles to play in chronic illness care, and service managers need to clearly define and support these roles.     

Practical challenges of conducting research into rheumatic fever in remote Aboriginal communities

Before embarking on an epidemiological study of acute rheumatic fever in remote Aboriginal communities, researchers engaged in the processes of community consultation, consent and household enrollment. Community expectations and time constraints are not necessarily those of the funding bodies, and a considerable investment of time and local engagement was required before the project proceeded with local support. The remoteness of the communities, harsh climate and limited infrastructure made working conditions difficult. Nevertheless, the study was completed and the results are being returned to the local councils and households. The research team continues to maintain its relationship with each study community.     

Improving diabetes care in the primary healthcare setting: a randomised cluster trial in remote Indigenous communities.

OBJECTIVE: To evaluate a system for improving diabetes care in remote Indigenous communities. DESIGN: Randomised, unblinded cluster trial over one year (1 March to 29 February 2000). PARTICIPANTS AND SETTING: Primary healthcare staff in 21 primary healthcare centres in the Torres Strait and Northern Peninsula Area (NPA) Health Service District, north Queensland, and 678 people with diabetes, mostly Torres Strait Islanders. INTERVENTION: Diabetes recall system established at eight of the 21 sites, as well as staff training in basic diabetes care, regular phone calls from the project officer, a two-monthly newsletter and a mid-project workshop. MAIN OUTCOME MEASURES: Regular checks of weight, blood pressure, eye and foot care, serum lipid levels and glucose monitoring and control, urinary albumin to creatinine ratio and serum creatinine levels, and administration of recommended vaccines; hospitalisation in the previous 12 months. RESULTS: There was improvement in most measures at most sites, except for blood pressure monitoring and control, and vaccination status. Intervention sites showed greater improvement in most indicators than control sites (combined relative risk [RR], 1.21; 95% CI, 1.03-1.43). The intervention group showed a 32% reduction in hospital admissions for diabetes-related conditions over the study period (P=0.012). At follow-up, patients in intervention sites were 40% less likely to be hospitalised for a diabetes-related condition than those in control sites (RR, 0.60; 95% CI, 0.41-0.86; P=0.007). CONCLUSION: A simple recall system, managed by local healthcare workers and supported by a diabetes outreach service, achieved significant improvements in diabetes care and reduced hospitalisations in a high-risk population.     

延续护理对我国糖尿病患者干预效果的 Meta 分析

目的：综合评价对我国糖尿病患者实施延续护理的干预效果。方法遵循 Cochrane 干预评价手册,严格制定文献检索策略,收集2000~2014年在中国生物医学数据库、万方、知网、维普数据库公开发表的关于糖尿病延续护理的随机对照试验。依据纳入和排除标准筛选文献,应用 RevMan5.0软件对数据进行 Meta 分析。结果8篇文献符合纳入标准,Meta 分析显示干预6个月后,干预组与对照组在并发症低血糖发生率[RR=0.69,95%CI (0.21,2.27),P =0.540]差异无统计学意义,在空腹血糖[WMD =-1.54,95%CI (-2.89,-0.19),P =0.030]差异有统计学意义。干预12个月后,干预组与对照组在并发症低血糖发生率[RR=0.34,95%CI (0.16,0.72),P =0.005],在空腹血糖[WMD =-1.03,95%CI (-2.78,0.72),P =0.250],在糖化血红蛋白[WMD =-1.73,95%CI (-2.43,-1.04),P <0.01]均有差异有统计学意义。干预18个月后,干预组与对照组在并发症低血糖发生率[RR=0.28,95%CI (0.12,0.67),P =0.004]差异有统计学意义。结论对我国对糖尿病患者进行延续护理干预能够降低患者的空腹血糖、糖化血红蛋白,减小低血糖的发生率,但对低血糖发生率的干预时间需大于6个月。     

糖尿病患者行为干预护理的效果分析

目的探讨糖尿病患者行为干预护理的效果。方法选择120例糖尿病患者,随机分组就常规护理与行为干预护理结果进行比较,分析临床资料。结果治疗后观察组血糖控制情况优于对照组,差异有统计学意义（P〈0．05）。观察组生活质量高于对照组,焦虑抑郁程度低于对照组,依从性高于对照组。结论加强糖尿病患者行为干预护理,可有效指导患者建立正确的生活行为方式,提高遵医依从性,更好地为疾病治疗服务。     

Lower than expected morbidity and mortality for an Australian Aboriginal population: 10-year follow-up in a decentralised community

OBJECTIVE: To examine mortality from all causes and from cardiovascular disease (CVD), and CVD hospitalisation rate for a decentralised Aboriginal community in the Northern Territory. DESIGN AND PARTICIPANTS: For a community-based cohort of 296 people aged 15 years or older screened in 1995, we reviewed hospital and primary health care records and death certificates for the period up to December 2004 (2800 person-years of follow-up). MAIN OUTCOME MEASURES: Mortality from all causes and CVD, and hospitalisation with CVD coded as a primary cause of admission; comparison with prior trends (1988 to 1995) in CVD risk factor prevalence for the community, and with NT-specific Indigenous mortality and hospitalisation rates. RESULTS: Mortality in the cohort was 964/100,000 person-years, significantly lower than that of the NT Indigenous population (standardised mortality ratio [SMR], 0.62; 95% CI, 0.42-0.89). CVD mortality was 358/100,000 person-years for people aged 25 years or older (SMR, 0.52; 95% CI, 0.23-1.02). Hospitalisation with CVD as a primary cause was 13/1000 person-years for the cohort, compared with 33/1000 person-years for the NT Indigenous population. CONCLUSION: Contributors to lower than expected morbidity and mortality are likely to include the nature of primary health care services, which provide regular outreach to outstation communities, as well as the decentralised mode of outstation living (with its attendant benefits for physical activity, diet and limited access to alcohol), and social factors, including connectedness to culture, family and land, and opportunities for self-determination.     

高血压病社区综合防治研究

目的探讨在社区采取综合干预措施对中重度高血压病患者预后的影响。方法将我院2005～2007年住院的150例中重度高血压病患者随机分为治疗组和对照组,治疗组接受钙拮抗剂和利尿剂治疗,并接受健康教育等非药物治疗以及定期随访,对照组按高血压病系统管理,定期随访坚持服药。结果治疗组患者治疗后的血压、血脂、血尿酸、血糖等较治疗前有显著性下降(p<0.01),较对照组亦有显著性下降(p<0.01);治疗组终点事件发生率低于对照组(p<0.01)。结论全面推行高血压病社区综合防治,以及加强健康教育可以提高高血压病的疗效及减少心脑血管疾病的发生。     

Electrocardiographic changes during exercise in asymptomatic men: 3-year follow-up.

Electrocardiographic (ECG) changes during maximal bicycle exercise and risk factors for coronary heart disease (CHD) were studied in 510 male civic employees who were followed for 3 years. Clinical CHD developed in 15 (24.6 percent) of the 61 men with an ischemic exercise ECG on the initial examination and in 11 (2.4 percent) of the 449 subjects with a normal initial exercise ECG. A normal maximal exercise ECG is no guarantee that severe CHD does not exist and that a subject will not soon sustain major myocardial damage; and an ischemic exercise ECG does not necessarily indicate underlying CHD. In the former group angina was the most frequent clinical CHD episode; in the latter group, infarction. Among those with an abnormal initial exercise ECG, CHD was most likely to develop in association with a poor exercise capacity. Subjects with subsequent clinical CHD and those with abnormal ECGs after 3 years tended to have a higher frequency of risk factors; subjects whose abnormal ECGs reverted to normal after 3 years tended to have a lower frequency of risk factors.     

浦东新区门诊精神分裂症患者服药依从性对其预后的影响（2年随访）

目的：将2007年1月1日至2008年12月31日浦东新区精神卫生中心门诊首次就诊的89例精神分裂症患者一年治疗的服药依从性分为依从性好组及依从性不良组,且进行2年随访,研究依从性对患者预后的影响。方法：采用自编、简明精神症状量表（BPRS）,SIMH治疗副反应量表（TESS）,MomingSide康复状态量表（MRSS）,社会功能缺陷筛查量表（SDSS）等调查量表,将数据输入SPSSII．5,采用参数及非参数统计方法进行分析。结果：依从性不良组（n：37）的复发人数和平均复发次数明显多于依从性好组（n：52）,差异有显著的统计学意义（P〈0.01）。随访末期,两组的MomingSide康复状态量表（MRSS）和社会功能缺陷筛查量表（SDSS）评分均得到进一步的改善,差异有显著的统计学意义（P〈0．01）。排除性别、年龄、精神疾病病程、心理干预及是否首发等因素后,复发次数与依从性的偏相关分析显示呈负相关（r=-0．2705,P：0．023）。结论：维持剂量越接近治疗剂量,复发的可能性越小。     

Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: A 15-year follow-up of low-income children in public schools

CONTEXT: Most studies of the long-term effects of early childhood educational interventions are of demonstration programs rather than large-scale public programs. Previous studies of one of the oldest federally funded preschool programs have reported positive effects on school performance, but effects on educational attainment and crime are unknown. OBJECTIVE: To determine the long-term effectiveness of a federal center-based preschool and school-based intervention program for urban low-income children. DESIGN, SETTING, AND PARTICIPANTS: Fifteen-year follow-up of a nonrandomized, matched-group cohort of 1539 low-income, mostly black children born in 1980 and enrolled in alternative early childhood programs in 25 sites in Chicago, Ill. INTERVENTIONS: The Chicago Child-Parent Center (CPC) Program (n = 989 children) provides comprehensive education, family, and health services and includes half-day preschool at ages 3 to 4 years, half- or full-day kindergarten, and school-age services in linked elementary schools at ages 6 to 9 years. The comparison group (n = 550) consisted of children who participated in alternative early childhood programs (full-day kindergarten): 374 in the preschool comparison group from 5 randomly selected schools plus 2 others that provided full-day kindergarten and additional instructional resources and 176 who attended full-day kindergartens in 6 CPCs without preschool participation. MAIN OUTCOME MEASURES: Rates of high school completion and school dropout by age 20 years, juvenile arrests for violent and nonviolent offenses, and grade retention and special education placement by age 18 years. RESULTS: Relative to the preschool comparison group and adjusted for several covariates, children who participated in the preschool intervention for 1 or 2 years had a higher rate of high school completion (49.7 % vs 38.5%; P =.01); more years of completed education (10.6 vs 10.2; P =.03); and lower rates of juvenile arrest (16.9% vs 25.1%; P =.003), violent arrests (9.0% vs 15.3%; P =.002), and school dropout (46.7% vs 55.0%; P =.047). Both preschool and school-age participation were significantly associated with lower rates of grade retention and special education services. The effects of preschool participation on educational attainment were greater for boys than girls, especially in reducing school dropout rates (P =.03). Relative to less extensive participation, children with extended program participation from preschool through second or third grade also experienced lower rates of grade retention (21.9% vs 32.3%; P =.001) and special education (13.5% vs 20.7%; P =.004). CONCLUSIONS: Participation in an established early childhood intervention for low-income children was associated with better educational and social outcomes up to age 20 years. These findings are among the strongest evidence that established programs administered through public schools can promote children's long-term success.     

2型糖尿病中医药干预疗效探讨

目的观察中医药干预2型糖尿病的临床疗效。方法 310例2型糖尿病患者根据其用药情况分为两组,对照组161例接受基础降糖治疗,研究组149例在对照组的基础上加用中医药治疗。观察两组患者干预后空腹血糖（FBG）、餐后2小时血糖（PBG）、糖化血红蛋白（HbAlc）和并发症情况,并对医疗费用以及因病平均年休天数进行统计。结果两组患者干预后FBG、PBG、HbAlc比较差异无统计学意义（P〉0.05）,研究组新增并发症例数明显少于对照组,差异有统计学意义（P〈0.05）,研究组年门诊费用稍多于对照组,但无统计学意义（P〉0.05）,研究组年住院费用、年总费用及因病平均年休天数明显少于对照组,差异有统计学意义（P〈0.05）。结论中医药干预对糖尿病特别是并发症有较好的疗效,并能明显减少医疗费用及因病平均年休天数,应加强并普及社区糖尿病患者的中医药干预。     

预防糖尿病足的护理与早期干预

糖尿病足是由于糖尿病的血管病变、神经病变和感染导致足和下肢组织破坏而引起的,其发生率较高,是糖尿病患者致残、致死的严重并发症之一。积极做好糖尿病足的预防与护理,是提高糖尿病患者的生活质量,减少糖尿病足致残率的有效办法。我科2007年2月2008年1月共收治糖尿病患者72例,现将其护理报告如下。     

护理干预对门诊中青年糖尿病患者的影响

目的护理干预对门诊中青年糖尿病患者的影响。方法将100例门诊2型中青年糖尿病患者随机分为干预组与对照组各50例,对照组有专科医生给予常规门诊治疗及健康教育;干预组除有专科医生给与治疗外,还配由一名经过专业培训的高年资护士通过建立个人电子健康档案、门诊电子病历、电话随访、组织讲座、面对面示范等方法对病人进行连续、全面的护理干预。观察两组患者的认知行为、生活方式的改变、血糖控制情况等进行效果评价。结果干预组与对照组比较,各项评分均明显高于对照组（P〈0.01）。结论护理干预能明显提高门诊在青年糖尿病患者对疾病的认知水平,改变不良生活方式,使血糖控制在理想范围,能预防和减少并发症的发生。     

产后随访干预对妊娠期糖尿病患者血糖控制及结局的影响

目的 探讨产后随访干预对妊娠期糖尿病患者血糖控制及结局的影响.方法 抽取2011年8月～2013年8月我院收治的140例妊娠期糖尿病患者,按照随机数字表法分为对照组和观察组,观察组患者在产后给予随访干预,对照组患者在产后不给予随访干预,对比观察两组患者的血糖控制情况以及对结局的影响.结果 产后第一次复诊结果显示,观察组妊娠期糖尿病患者产后糖代谢异常发生率明显高于对照组（P＜0.05）;6个月后,观察组患者在糖代谢异常发生率上明显低于对照组（P＜0.05）,且在剖宫产、早产、新生儿窒息、巨大儿、胎儿宫内窘迫以及新生儿低血糖等妊娠结局方面,观察组患者的发生率同样要低于对照组（P＜0.05）.结论 妊娠期糖尿病患者在产后糖代谢异常发生率较高,在产后给予患者随访干预能够显著降低糖代谢异常发生率,对患者的血糖情况能够进行有效控制.     

An interim report of an intervention strategy for diabetes care in Jamaica

The high prevalence (17.9%) of diabetes mellitus and its attendant costs have been recognized for some time. The diabetic public has hitherto been too oriented to seeking health care at the secondary and tertiary health care centres; a much too costly approach. As a part of a wellness promotion thrust as well as an awareness and intervention strategy, a number of health care agencies have collaborated in a training programme of lay diabetes facilitators. This was intended to allow a domino effect of "each one teach one" within the community. This intervention programme was undertaken over an 18-month period. No significant changes were achieved in glycaemia levels. The impact on hospital admissions and community awareness is yet to be assessed. Laboratory results indicated good correlation between glycosuria and hyperglycaemia. This could influence the thrust in maintaining glycosuria assessment alongside blood glucose monitoring. This approach would have a cost benefit for government clinics islandwide. Whilst it may be difficult to identify any one parameter that may be responsible for change, it will be possible to assume that this intervention strategy, the only innovation in the health care delivery modalities, may have contributed.     

持续护理干预对2型糖尿病治疗依从性和疗效的评价

目的 探讨持续性护理干预对2型糖尿病治疗的依从性和疗效.方法 将112例住院2型糖尿病患者随机分为对照组56例和干预组56例.对照组入院实施常规治疗和护理,出院后发给健康教育手册.干预组入院便采取常规治疗和有效护理干预,院后持续性跟踪随访和合理的指导,包括健康生活方式、用药行为、情绪控制、自我监测等.结果 6个月后干预组与对照组比较,两组依从性差异有统计学意义(P<0.05),血糖、糖化血红蛋白控制有显著性差异(P<0.01);干预组治疗效果明显优于对照组.结论 持续护理干预能明显提高治疗的依从性、自控能力及调控血糖能力.延缓和减轻并发症的发展,利于疾病的良好控制.