Development of family planning in the German Democratic Republic

In the German Democratic Republic family planning is termed "marriage and sexual guidance," and has been offered at Leipzig University Gynecological Clinic since 1949, and in over 130 state run "family advisory centers" since the 1966 law authorized them. Services include contraception, abortion for women under 16, over 40 or with specific medical indications, marriage counseling, infertility diagnosis, psychiatric and legal aid. These services are free to all citizens. Conventional contraception, IUDs (Lippes loops and Dana devices), and 2 doses of combined pills are offered (lower dose contains 2 mg chlormadinone acetate and .08 mg mestranol). Training is available for doctors, women welfare workers and interested laymen at the 2 main centers at Leipzig and Rostock.     

Users of three psychiatric services: profile and opinion

This study aimed to characterize mental patients and their companions at three psychiatric services; to identify diseases, diagnoses and treatments; to learn about their expectations and opinions about mental illness and psychiatric care. Methodology: Patients with mental disorders and their companions (750) at three care services (Emergency Unit, Psychosocial Care Center and Mental Health Clinic) answered the Clinical-Social Characterization Questionnaire and the Opinion Measurement Scale on concepts and psychiatric care. Results: Single patients with unstable relations with their partners, low educational level, unemployed, with little information about their diagnoses and treatments. Medication treatments and low commitment levels were predominant. Many patients had acquired the illness over the last five years. Subjects at the three services revealed diverging opinions regarding concepts and care.     

Health Beliefs and Co-morbidities Associated with Appointment-Keeping Behavior Among HCV and HIV/HCV Patients

Appointment-keeping behavior is an important requisite for HCV linkage and treatment initiation. In this study we examine what impact hepatitis C (HCV) knowledge and attitudes has on appointment-keeping behavior among a cohort of HCV and HCV/HIV patients. Knowledge scores and attitude scales, obtained from a cross-sectional survey, were correlated with proportion of appointments kept 1 year prior to taking the survey. Independent risk factors for missing appointments were examined by multiple regression analysis. 292 HCV patients completed the survey, and 149 (51 %) were co-infected with HIV. HCV patients kept 67.5 ± 17.4 % of their total appointments and a similar proportion (67 ± 38.2) of Liver Clinic appointments, but they attended a higher proportion (73 ± 24.4) of Primary Care Clinic appointments. However, certain health beliefs, psychiatric illness, and HIV co-infection were independently associated with lower levels of appointment-keeping behavior. HCV knowledge was not associated with appointment-keeping behavior. Health beliefs, psychiatric illness, and HIV co-infection are associated with missing appointments, but no link between knowledge and appointment keeping behavior is apparent. In order to increase engagement into HCV care, HCV care coordination programs need to focus on addressing health beliefs and providing resources to those at highest risk for missing appointments.     

Development of semi-inpatient care

Changes in the concepts of psychiatric care have led to a relaxation of the strict division of care into out-patient and inpatient care. The complex care of patients, the demand for more diagnosis-specific care of good quality require more multifarious kinds of care. Concerning patients which are not in need of the comprehensive care performances necessary to bedridden patients for other specialized fields. As can be seen from literature, this kind of care has not yet taken its due place in practice despite good experience over a period of more than 50 years. This would require unisonous views of semi-in-patient care, its documentation and mode of accounting up to issues of social insurance.     

Primary intensive care: pilot study of a primary care-based intervention for high-utilizing patients.

This pilot study was conducted to determine whether primary care patients with perceived inappropriate high healthcare utilization would require fewer emergency or inpatient services while enrolled in a weekly multidisciplinary clinic. Seventeen high-utilizing or difficult management patients of a primary care center were referred for the special intervention, Primary Intensive Care (PIC). Although not selected for the presence of psychopathology, 16 patients had comorbid psychiatric diagnoses. Patients followed in the PIC Clinic had significantly lower inpatient and emergency department use during their enrollment in the intervention when compared to the matched pre-enrollment time period, although the total hospital cost differences did not reach statistical significance. Patient and staff satisfaction was high, although the intervention was very difficult for the providers.     

Betreute Wohnformen für chronisch schizophren Erkrankte

This contribution presents data from a study of mental health services assessing developments in five groups of patients with chronic schizophrenic disorders. The patients live in different types of residential care recently established in a region of eastern Germany. To illustrate patients currently to be deinstitutionalized the first part focuses on sociodemographic and psychopathological features, social disabilities, and normative needs for psychiatric care of those still in the nursing home area of a large psychiatric hospital. These data are compared to those from a patient group already dehospitalized in social therapeutic hostels, which leads to some conclusions for the health policies regarding further deinstitutionalization. It appears that this process should be interrupted to improve the concepts of future social therapeutic hostels and meet the needs for caring for patients still awaiting dehospitalization. In the second part, data on psychopathology, social disabilities, and normative needs for the psychiatric care of cohorts living autonomously in their own apartments demonstrate that the principle of needs-oriented care is also not achieved systematically concerning sheltered community residential care. Currently the allocation of this type of residential care is not based directly at the level of individual psychopathological symptoms and social inabilities. These findings underscore the demand for standardized individual assessments of needs for care and for a dynamic and needs-oriented approach to community care.     

Utilization of hospital services. A comparison of internal medicine and family practice

Five hundred twenty new patients were randomly and prospectively assigned to receive care in the Internal Medicine Clinic or Family Practice Clinic of a large university hospital. Previous analyses of outpatient data demonstrated that the frequency of visits to the clinic of primary care, acute care clinic, emergency room, and consultant clinics were all significantly higher for patients randomized to internal medicine compared with family practice. In the present study, patients' charts were reviewed for information regarding hospitalizations. During the 3.4-year study period, there were a total of 61 hospital admissions for internal medicine (35 of 249 patients), and 58 for family practice (27 to 271 patients). Age (mean 47 years) and sex of patients in both groups were equivalent. The average total cost of hospitalization for each patient was greater for those randomized to the Internal Medicine Clinic: $7,193 for internal medicine patients as compared with $5,764 for family practice patients. The professional costs per hospitalization showed greater variation: $913 for Internal Medicine Clinic patients and $629 for Family Practice Clinic patients. Internal Medicine Clinic patients had a longer mean length of hospitalization (7.5 days) when compared with that of Family Practice Clinic patients (6.3 days). It can be concluded that in this clinical environment the hospitalization patterns are different for patients assigned to the Internal Medicine Clinic compared with the Family Practice Clinic: both cost and length of care for hospitalization are less for those followed by the Family Practice Clinic.     

The urban hospital system in Leipzig at the turn of the century

The development of the hospital in Germany up to 1914 had been realized by the establishment of medicine of natural science, combined with a sensible progress of diagnostics and therapy. Thus the character of the stationary care changed in Leipzig by 1900. This process had been supported by an organization separating care of patients from those of poor subjects. A reconstruction and improvement of the municipal hospitals could be gained by the erection of the Nursing Home for Mental Cases in Leipzig-D?sen (1901), of the Leipzig Tuberculous Sanatorium Sorg at Adorf (1906) and of the Municipal Hospital St. Georg (1911-1913).     

Menninger Clinic finds new home. Lucrative partners draw psychiatric institution to greener pastures in Houston

The Menninger Clinic has found a new home. Two lucrative partners in late September lured the renowned psychiatric clinic away from its roots in Topeka, Kan., to financially greener pastures on the sprawling campus of Texas Medical Center in Houston. The 143-bed clinic has faced dwindling revenue and increasing costs, resulting from a confluence of factors such as a fall in government reimbursement and the rise of managed care.     

Gatekeeping in primary care: a comparison of internal medicine and family practice

Five hundred twenty new patients were randomly and prospectively assigned to receive their care in the Internal Medicine Clinic or Family Practice Clinic of a large university hospital. The patients were followed by residents in training under the supervision of board-certified internists or family physicians. After a mean length of care of slightly over two years, the charts were reviewed for frequency of visits to primary care providers (internal medicine or family practice), Emergency Room, Acute Care Clinic, and all clinics other than the two primary care clinics. The records were also reviewed for laboratory tests ordered. Frequency of visits to the clinic of primary care, Emergency Room, Acute Care Clinic, and broken appointments were all significantly higher for patients randomized to the Internal Medicine Clinic. In addition, the median total annual cost of laboratory tests for patients followed by internal medicine physicians was significantly higher, largely because of higher laboratory charges generated by the specialist consultants. Over the study period, internal medicine patients had a significantly higher number of visits to all nonprimary care clinics and specifically to the dermatology, obstetrics and gynecology, and general surgery consultant clinics. It can be concluded that in this clinical environment, the practice styles of internal medicine and family practice are different.     

Acute psychiatric admissions from an out-of-hours Casualty Clinic; how do referring doctors and admitting specialists agree?

Background  

Over the last decades there has been an increasing pressure on the acute psychiatric wards in Norway. The major contributor to psychiatric acute admissions at the University Hospital of North Norway in the city of Troms? in 2001 was the GP-based Troms? Casualty Clinic, only open out-of-hours. We explored all acute psychiatric referrals from Troms? Casualty Clinic in 2001. The purpose of the study was to characterize the admissions and assess the agreement between the referring doctors and the hospital specialists according to the need for hospitalization, agreement on application of the law and the diagnostic evaluation to assess whether the admissions were appropriate.     

Telemedicine applications in occupational medicine

Telemedicine combines telecommunication technology and medicine to increase access to health care services for patients living in remote areas and enhance the efficiency of delivering that care. This article describes the results of a Mayo Clinic pilot study on the use of telemedicine in an occupational medicine clinic for Mayo Clinic employees and their dependents. The study involved 21 patients who came for initial evaluations for work-related problems or injuries, follow-up visits, visits for acute problems such as low-back pain, and periodic health evaluations. It found that patients and providers were comfortable with the technology after a short training session and satisfied with the outcomes of the visits. More rigorous research evaluating the applications of telemedicine in occupational health care is needed.     

Mental Health in Primary Care: Perceptions of Augmented Care for Individuals With Serious Mental Illness

Individuals with serious mental illness are at increased risk of developing secondary physical illnesses because of lifestyle and psychiatric treatment–related factors. Many individuals with mental illness participate in primary care clinics, such as Placer County Community Clinic (PCCC), which provides primary care and medication-only psychiatric services to low-income county residents. This qualitative study describes an augmented care program provided to this population at PCCC and explores participant experiences with that program. The augmented program consisted of a full-time social worker and part-time registered nurse working as a team to coordinate care between providers, and provide psychosocial education and illness management support. Previous studies have demonstrated that similar programs result in improved clinical outcomes for people with mental illness but have largely not included perspectives of participants in these pilot programs. This article includes participant reports about medical service needs, barriers, and beneficial elements of the augmented program. Medical service needs included the need to provide input in treatment and to be personally valued. Barriers ranged from doubts about provider qualifications to concerns about medication. Elements of the augmented care program that participants found beneficial were those involving care coordination, social support, and weight management support.     

Non-cardiac chest pain: a retrospective cohort study of patients who attended a Rapid Access Chest Pain Clinic

BACKGROUND: Rapid Access Chest Pain Clinics have recently been introduced to assist in the management of primary care patients experiencing suspected cardiac chest pain. OBJECTIVE: To study the longer term outcome for patients referred to a Rapid Access Chest Pain Clinic and then given a non-cardiac diagnosis. METHODS: The study collected retrospective data from a cohort of all patients attending the Rapid Access Chest Pain Clinic based in the cardiorespiratory Department at the York District Hospital, England. Questionnaires were sent to all patients who attended the Rapid Access Chest Pain Clinic during the previous 14 months and were diagnosed with non-cardiac chest pain. Participants reported on their chest pain, subsequent episodes of primary and secondary care and their beliefs about causation of pain. RESULTS: Of the patients referred to the Rapid Access Chest Pain Clinic, 235 (52%) did not have cardiac chest pain. Of these patients, 161 (69%) returned the questionnaire, nearly half of whom reported ongoing chest pain. The mean time since Clinic attendance was approximately 8 months and the median duration of ongoing chest pain was 5.4 months. Women were twice as likely as men to continue to be experiencing pain but did not report more frequent or severe pain on average. More than 50% of the non-cardiac group were not convinced by their negative cardiac diagnosis. CONCLUSION: There is an ongoing challenge to support patients with non-cardiac chest pain, including the provision of reassurance that their pain is very unlikely to be caused by their heart.     

The Indochinese Psychiatry Clinic: trauma and refugee mental health treatment in the 1990s

The Indochinese Psychiatry Clinic (IPC), located in Boston, was founded in 1981 to meet the special needs of traumatized Cambodian, Vietnamese, and Laotian refugees resettling in the Boston area. Over the past 16 years, IPC has pioneered the field of refugee mental health and the treatment of the psychological and social sequelae of mass violence and torture. IPC developed the bicultural model of psychiatric treatment of refugees suffering from trauma-related mental disorders, which utilizes a multidisciplinary, bicultural team approach that emphasizes understanding the patient's trauma history within the appropriate cultural, social, and political context. This article summarizes IPC's background, patient profile, clinical approach, service elements, and funding structure. Recent immigration and welfare reform legislation will have a harsh impact on the population of refugees who are disabled due to the psychosocial consequences of their traumatic experiences. This legislation and the restrictions on mental health care imposed by public managed care will also affect the providers of their mental health care.     

Application of key health care concepts in the development of a paediatric upper limb hypertonicity surgery clinic

The task of establishing and managing a paediatric Upper Limb Hypertonicity Surgery Clinic provided an opportunity to investigate key concepts in health care delivery in order to enhance the quality of the service for patients and their families. Several concepts were found to be fundamental to effective service development and delivery: client-centred approach, collaboration, continuum of care, evidence-based practice and outcome evaluation. This report describes the processes and protocols of the Upper Limb Hypertonicity Surgery Clinic and discusses both the positive and challenging aspects of applying key health care concepts in clinical practice.     

Psychiatric nurse reports on the quality of psychiatric care in general hospitals

Although acute inpatient psychiatric care has changed dramatically over the past 2 decades, little is known about how these changes have affected the quality of care, psychiatric nurse staffing, or patient outcomes. The purpose of this report is to explore the quality of care, quality of the practice environment, and adverse events as assessed by psychiatric nurses in the general hospital setting. The study sample consisted of 456 registered nurses permanently assigned to psychiatric units, compared with a larger sample of 11,071 registered nurses who work permanently on medical, surgical, or medical-surgical units. Compared with nonpsychiatric nurses, psychiatric nurse characteristics reveal an older, more experienced workforce, with a higher proportion of male nurses. Nurses rated quality of patient care lower in the psychiatric specialty than in the medical-surgical specialty. Furthermore, psychiatric nurses reported significant concern about the readiness of patients for discharge and higher incidence of adverse events. They also experienced more verbal abuse, physical injuries, and complaints from patients and families. Collectively, the results from this study underscore the organizational problems and quality-of-care issues that cause psychiatric nurses in general hospital settings to evaluate their work environments negatively.     

Medizinische Versorgung und therapeutische Optionen unter gesundheitsökonomischen Aspekten bei psychiatrischen Patienten in Deutschland am Beispiel schizophrener und depressiver Störungen

Optimal and effective medical care of patients suffering from psychiatric disorders and their integration into society leads undoubtedly not only to a higher quality of life of the person affected, but also to a reduction of direct and indirect disease-related costs such as loss of earnings and disability pension. Both schizophrenia and depressive disorder display an early age of onset and inclination to a chronic course under inadequate medical care and thus are interesting examples for diseases with enormous direct and indirect disease-related health costs. We want to illustrate with these diseases the necessity for further effort, more extensive financial support, and the will for change to maintain the standard of medical care for psychiatric patients which has been achieved during the last 20 years in Germany. To achieve this goal, all sectors of the healthcare system have to recognize the health economic effects of inadequate medical care of psychiatric patients either as a result of understaffing, insufficient application of therapeutic options, inadequate exploitation of the care system, or as an effect of inaccurate legislation and to draw the right conclusions together. Furthermore, more research on the care system of psychiatric patients dealing with economic aspects is required.     

Bipolar illness in primary care: an overview

Primary care providers are in the front line of detecting and diagnosing psychiatric illness. Managed care barriers to direct psychiatric treatment have made it necessary for primary care providers to increase their sophistication in the recognition of psychiatric disorders. Primary care providers often formulate provisional diagnoses and initiate treatment or specialty referral in spite of the time constraints of the primary care setting. The patient presenting in primary care with an affective disturbance must be evaluated for a major mood disorder, which includes unipolar and bipolar illness. Research has shown that more patients than previously estimated have milder forms of bipolar illness disorder, such as bipolar type II and cyclothymia. Patients with these milder forms of bipolar are less likely to present for treatment in a psychiatric setting and more likely to share symptoms of the illness in a primary care setting. This article provides an overview for the primary care provider in the detection, assessment, and treatment of bipolar patients with an emphasis on the differentiation of unipolar and bipolar depression.     

Managing physical illness in people with severe mental illness

People with severe mental illness have poor physical health, and increased morbidity and mortality compared to the general population. Community-based mental health care has led to hospital doctors being more involved in the physical care of psychiatric patients. This paper focuses on key issues in the medical management of psychiatric patients in a general hospital setting.