A pharmaceutical needs assessment in a primary care setting.

BACKGROUND: As part of a reconfiguration of its general medical services, Ardach Health Centre has integrated a community pharmacist into the centre to provide pharmaceutical care. In order to systematically identify areas of 'pharmaceutical need', a needs assessment was carried out during October 1997. AIM: To prioritize and assist the planning of pharmaceutical care provision within the centre, such that maximum gain could be achieved from inevitable limited resources. METHOD: A four-stage pharmaceutical needs assessment method was created around a selection of techniques: gap analysis, the nominal group technique, and rapid participatory appraisal. This was then applied to a random sample of people drawn from the patient register of Ardach Health Centre and all the health care professionals associated with their care. RESULTS: Through the four-stage process, a pharmaceutical service priority league table was constructed to reflect the unmet pharmaceutical needs of patients and their primary health care providers. The table provided a structured framework around which pharmaceutical service provision within the health centre could be planned. CONCLUSION: We have developed a pragmatic, systematic method of identifying the prevalence of unmet pharmaceutical needs of a community. The assessment assisted service selection, balancing what should be done with what could be done and what could be afforded.     

Evaluating a mental health assessment for older people with depressive symptoms in general practice: a randomised controlled trial.

BACKGROUND: There is a lack of evidence on the most effective primary care management of older people with minor depression. AIM: To evaluate a follow-up assessment by the community mental health team (CMHT) for older people with depressive symptoms identified by practice nurses at a health check for people over the age of 75 years. DESIGN OF STUDY: A pragmatic randomised controlled trial. SETTING: A single large general practice in Leicestershire. METHOD: Patients receiving a health check administered by a practice nurse and scoring 5 or more on the 15-item Geriatric Depression Scale (GDS15) were randomised to either follow-up by the CMHT or routine general practitioner (GP) care. The GDS15 score was measured at the subsequent health check 18 months later. RESULTS: Forty-seven patients were randomised to CMHT assessment and 46 to routine GP care. Uptake of the intervention was 72% (n = 34). At the follow-up health check a greater proportion of the control group had improved GDS15 scores (P = 0.08). Following assessment, the CMHT recommended their further involvement in the care of 12 patients and this was authorised by patients' GPs in six cases. CONCLUSIONS: A follow-up mental health assessment by a member of the local CMHT was not effective in improving outcomes for mildly depressed older people. Other than random error possible reasons for this include the length of follow-up and a failure to meet raised expectations among the intervention group. If complex referral procedures do not improve outcomes for this group, then specialist community services should play a more prominent part in the training of practice staff to care for their depressed older patients.     

Applying community-oriented primary care methods in British general practice: a case study.

BACKGROUND: The '75 and over' assessments built into the 1990 contract for general practice have failed to enthuse primary care teams or make a significant impact on the health of older people. Alternative methods for improving the health of older people living at home are being sought. AIM: To test the feasibility of applying community-oriented primary care methodology to a relatively deprived sub-population of older people in a relatively deprived area. DESIGN OF STUDY: A combination of developmental and triangulation approaches to data analysis. SETTING: Four general practices in an inner London borough. METHOD: A community-oriented primary care approach was used to initiate innovative care for older people, supported financially by the health authority and practically by primary care academics. RESULTS: All four practices identified problems needing attention in the older population, developed different projects focused on particular needs among older people, and tested them in practice. Patient and public involvement were central to the design and implementation processes in only one practice. Innovations were sustained in only one practice, but some were adopted by a primary care group and others extended to a wider group of practices by the health authority. CONCLUSION: A modified community-oriented primary care approach can be used in British general practice, and changes can be promoted that are perceived as valuable by planning bodies. However, this methodology may have more impact at primary care trust level than at practice level.     

Prevalence and correlates of perceived unmet needs of people with systemic lupus erythematosus

To assess the prevalence and correlates of perceived unmet need among people with systemic lupus erythematosus (SLE) 386 people with SLE, recruited from a support association in NSW, Australia, completed a mail-back survey that included 97 items measuring perceived unmet needs across seven domains: physical, daily living, psychological/spiritual/existential, health services, health information, social support and employment/financial. Ninety-four percent of participants had at least one unmet need. The highest levels of unmet need were tiredness (81%); pain (73%); not being able to do things one used to (72%); fear of exacerbation (72%); sleeping problems (70%); anxiety and stress (69%); and feeling down (68%). Five of the highest levels of unmet needs were in the psychological domain. Researchers concluded that current health care delivery is not adequately meeting some of the needs of people with SLE. A comprehensive needs assessment questionnaire for all SLE patients could help providers manage protocols more effectively.     

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.     

Membership by Assessment of Performance: developing a method for assessing established general practitioners.

Over 200 general practitioners (GPs) and others have contributed to the development of Membership by Assessment of Performance (MAP): a new scheme for assessing established GPs. By means of a Delphi consultation with a broad cross-section of the profession, a working conference, piloting with potential candidates, and repeated checking with reference panels, the assessment was developed within two years. We report the development of MAP, including the results of the Delphi consultation, which asked 'Which aspects of a general practitioners performance are important to assess?'.     

Previously unidentified morbidity in patients with intellectual disability

BACKGROUND: Adults with a learning disability frequently have unmet health needs. The cause for this is complex and may be related to difficulties in accessing usual primary care services. Health checks have been widely recommended as a solution to this need. AIM: To determine the likelihood that a structured health check by the primary care team supported by appropriate education would identify and treat previously unrecognised morbidity in adults with an intellectual disability. DESIGN OF STUDY: Individuals were identified within primary care teams and a structured health check performed by the primary care team. This process was supported by an educational resource. Face-to-face audit with the team was performed 3 months following the check. SETTING: Forty general practices within three health authorities in south and mid-Wales participated. They had a combined registered patient population of 354 000. METHOD: Health checks were conducted for 190 (60%) of 318 identified individuals; 128 people moved, died, withdrew from the study, or refused to participate. RESULTS: Complete data were available on 181 health checks; 51% had new needs recognised, of whom 63% had one health need, 25% two health needs, and 12% more than two. Sixteen patients (9%) had serious new morbidity discovered. Management had been initiated for 93% of the identified health needs by the time of audit. This study is the first to identify new disease findings in a primary care population and the likelihood that such disease will be treated. CONCLUSIONS: The findings reflect a concern that current care delivery leaves adults with an intellectual disability at risk of both severe and milder illness going unrecognised. Health checks present one mechanism for identifying and treating such illness in primary care.     

Treatment of mucopolysaccharidosis type II (Hunter syndrome): a Delphi derived practice resource of the American College of Medical Genetics and Genomics (ACMG)

Mucopolysaccharidosis, type II (MPS II, MIM 309900) is a severe lysosomal storage disease with multisystem involvement. There is one product approved by the FDA, an enzyme replacement therapy, based on a phase III trial in older, attenuated MPS II individuals. Guidance on treatment of MPS II is lacking, not only in general, but for specific clinical situations. A previous systematic evidence-based review of treatment for MPS II demonstrated insufficient strength in all data analyzed to create a definitive practice guideline based solely on published evidence. The American College of Medical Genetics and Genomics (ACMG) Therapeutics Committee conducted a Delphi study to generate an MPS II clinical practice resource of the treatment for these individuals for the genetics community, based on the evidence-based review and subsequent literature. This report describes the process, including consensus development and areas where consensus could not be obtained due to lack of quality evidence. Recommendations from the Delphi process were generated, and areas were highlighted that need further study to help guide clinical care of these individuals.     

EAACI Position paper on the standardization of nasal allergen challenges

Nasal allergen challenge (NAC) is an important tool to diagnose allergic rhinitis. In daily clinical routine, experimentally, or when measuring therapeutic success clinically, nasal allergen challenge is fundamental. It is further one of the key diagnostic tools when initiating specific allergen immunotherapy. So far, national recommendations offered guidance on its execution; however, international divergence left many questions unanswered. These differences in the literature caused EAACI to initiate a task force to answer unmet needs and find a consensus in executing nasal allergen challenge. On the basis of a systematic review containing nasal allergen challenges of the past years, task force members reviewed evidence, discussed open issues, and studied variations of several subjective and objective assessment parameters to propose a standardized way of a nasal allergen challenge procedure in clinical practice. Besides an update on indications, contraindications, and preparations for the test procedure, main recommendations are a bilaterally challenge with standardized allergens, with a spray device offering 0.1 mL per nostril. A systematic catalogue for positivity criteria is given for the variety of established subjective and objective assessment methods as well as a schedule for the challenge procedure. The task force recommends a unified protocol for NAC for daily clinical practice, aiming at eliminating the previous difficulty of comparing NAC results due to unmet needs.     

Educational intervention for older people with asthma: A randomised controlled trial

ObjectivesTo improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns.MethodsCommunity dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation. Outcome measures: asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention.ResultsIntervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months.ConclusionAsthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs.Practical implicationsUse of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.     

Consistency and Standardization of Color in Medical Imaging: a Consensus Report

This article summarizes the consensus reached at the Summit on Color in Medical Imaging held at the Food and Drug Administration (FDA) on May 8–9, 2013, co-sponsored by the FDA and ICC (International Color Consortium). The purpose of the meeting was to gather information on how color is currently handled by medical imaging systems to identify areas where there is a need for improvement, to define objective requirements, and to facilitate consensus development of best practices. Participants were asked to identify areas of concern and unmet needs. This summary documents the topics that were discussed at the meeting and recommendations that were made by the participants. Key areas identified where improvements in color would provide immediate tangible benefits were those of digital microscopy, telemedicine, medical photography (particularly ophthalmic and dental photography), and display calibration. Work in these and other related areas has been started within several professional groups, including the creation of the ICC Medical Imaging Working Group.     

Consensus minimum standards for use in a trainer''s report for summative assessment in general practice.

BACKGROUND: Summative assessment of general practitioner registrars is to be introduced in September 1996, one component of which will be a report by the trainer. Standards must be set and guidance provided as to the most appropriate ways of obtaining evidence for the trainer's assessment. AIM: The first aim of this study was to set consensus minimum standards for 30 items that are likely to form the content of a trainer's report; the second aim was to provide a consensus view on the most appropriate methods of assessment to be used by trainers. METHOD: A consensus conference was held in March 1995 during which the 30 items were discussed by a group of 30 general practitioners, of whom 27 were experienced trainers. This resulted in a draft document that was circulated to the conference attenders and other experts for consultation. RESULTS: Draft minimum standards were produced for all 30 items after the consensus conference with a mean of 2.5 standards for each item. Of those involved in the consultation exercise, 82% replied. Most of the revisions suggested at this stage were of a minor nature; the only major revision was to divide one item into two, resulting in a final total of 31 items. All but one of the 80 standards could be assessed by direct observation; 41 (51%) could be assessed by tutorial-based discussion and 61 (76%) by methods specific to that standard. Trainers or their practice partners were viewed as acceptable sources of evidence for all items and hospital consultants and primary health care team members were viewed as acceptable for just over half of the items. CONCLUSION: Standards for use by trainers when providing a general practitioner report for the summative assessment of registrars have been developed by consensus conference and have been subjected to review by consultation. Acceptable methods by which registrars could be assessed against these standards, and suitable personnel who could provide evidence, have also been suggested.     

A randomized controlled trial of a brief educational and psychological intervention for patients presenting to a cardiac clinic with palpitation

BACKGROUND: We sought to determine whether a brief psycho-educational intervention reduced disability in patients with benign palpitation. METHOD: In a pragmatic randomized controlled trial within a cardiology clinic at a district general hospital, 80 consecutive patients diagnosed as having benign palpitation--either palpitation due to awareness of extrasystoles or sinus rhythm--with associated distress or disability were randomized to an intervention group (usual care plus nurse-delivered intervention based on cognitive-behavioural principles) or to a control group (usual care). Principal outcome was difference in proportion of participants with good or excellent researcher-rated activity levels at 3 months. Subsidiary outcomes were self-rated symptoms, distress and disability, researcher-rated unmet treatment needs. RESULTS: The principal outcome showed a statistically and clinically significant benefit for the intervention group, with a number needed to treat of 3 (95% CIs 2 to 7). All but one subsidiary outcomes also showed a difference in favour of the intervention group, and several differences reached statistical significance. Significantly more of the control group had unmet treatment needs at 3 months. CONCLUSIONS: A brief, nurse-delivered, psycho-educational intervention, was an effective treatment for benign palpitation. Further evaluation, including assessment of cost-effectiveness, is needed. The findings have application to the care of patients presenting with other types of 'unexplained' medical symptoms.     

Educational intervention for older people with asthma: A randomised controlled trial

Objectives

To improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns.

Methods

Community dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation. Outcome measures: asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention.

Results

Intervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months.

Conclusion

Asthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs.

Practical implications

Use of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.     

IMIA Working Group 15: technology assessment and quality development in health informatics

The working group on technology assessment and quality development in health informatics was established as a follow-up to the recommendations made at the IMIA-ISTAHC working conference in 1990. The working group was approved by the IMIA General Assembly at Kyoto, September, 1993. The working group aims to further develop the field of technology assessment and quality development in health informatics, by: promoting consensus development on methodological issues; promoting comprehensive assessment of health care information technologies, for instance by providing expertise; demonstrating the value and importance of assessment of health care information technologies, to health care decision makers, health care providers and developers of information technologies.