Diagnosis and management of dementia in primary care: Exploratory study

Objective

To assess the current identification and management of patients with dementia in a primary care setting; to determine the accuracy of identification of dementia by primary care physicians; to examine reasons (triggers) for referral of patients with suspected dementia to the geriatric assessment team (GAT) from the primary care setting; and to compare indices of identification and management of dementia between the GAT and primary care network (PCN) physicians and between the GAT and community care (CC).

Design

Retrospective chart review and comparisons, based on quality indicators of dementia care as specified in the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, were conducted from matching charts obtained from 3 groups of health care providers.

Setting

Semirural region in the province of Alberta involving a PCN, CC, and a GAT.

Participants

One hundred patients who had been assessed by the GAT randomly selected from among those diagnosed with dementia or mild cognitive impairment by the GAT.

Main outcome measures

Diagnosis of dementia and indications of high-quality dementia care listed in PCN, CC, and GAT charts.

Results

Only 59% of the patients diagnosed with dementia by the GAT had a documented diagnosis of dementia in their PCN charts. None of the 12 patients diagnosed with mild cognitive impairment by the GAT had been diagnosed by the PCN. Memory decline was the most common reason for referral to the GAT. There were statistically significant differences between the PCN and the GAT on all quality indicators of dementia, with underuse of diagnostic and functional assessment tools and lack of attention to wandering, driving, medicolegal, and caregiver issues, and underuse of community supports in the PCN. There was higher congruence between CC and the GAT on assessment and care indices.

Conclusion

Dementia care remains a challenge in primary care. Within our primary care setting, there are opportunities for synergistic collaboration among the health care professionals from the PCN, CC, and the GAT. Currently they exist as individual entities in the system. An integrated model of care is required in order to build capacity to meet the needs of an aging population.     

Establishing a family practice: a model to determine economic feasibility

The availability of adequate health care is a major concern of urban and rural citizens. Community leaders and hospital administrators attempting to recruit family physicians and health care providers considering a specific community need a method by which they can evaluate a community's potential for supporting a first or additional primary care physician. To develop this method, a detailed survey of family practices geographically dispersed throughout Oklahoma was conducted in 1989. Data collected from family physicians and their administrative staff reflected the volume of ambulatory and hospital visits and the direct and indirect costs of the practice over the previous 12 months. Using the fixed and operating cost data, as well as number of patient visits and patient care revenue, we designed a model to project the economic feasibility of establishing a family practice in a specific community. This model can be used to project the number of visits a community can generate for a prospective family physician, as well as the direct and indirect costs, gross revenue, and net income of the practice.     

The Diagnosis and Treatment of Epilepsy

The vast rural areas in Colorado and Wyoming complicate the problems of providing continuing education and improving health care delivery. The Regional Medical Program for these states has tried to provide rural physicians with knowledge, technics and equipment equal to those of physicians in urban centers. One solution has been to bring continuing education courses to the smaller hospitals, so that health care personnel can attend courses without giving up their patient load.     

A primary healthcare approach to the management of chronic disease in Ethiopia: an example for other countries

Chronic non-communicable diseases such as epilepsy, diabetes, cardiac disease and hypertension represent a growing but neglected burden in developing countries. Rural sufferers, distant from health facilities, bear this most acutely. In response, a community care programme has been developed at Jimma University Hospital and its allied health centres in rural southwest Ethiopia. This involves general duty nurses at rural health centres being trained to provide care for chronic disease patients, with regular supervision from the hospital physicians. The programme allows treatment to be provided away from the main hospital so that those who cannot afford to travel can access care near their homes. Improved access increases the request for care, and helps to address the large unmet need for chronic disease treatment. This is a good model in which rural healthcare delivery through a team can bring widespread benefit. In this article chronic disease care is discussed with a particular focus on diabetes and epilepsy. The model can be replicated in more or less developed countries and may also be relevant for HIV care.     

Pharmaceutical care in community pharmacies: practice and research in Switzerland

OBJECTIVE: To describe the current situation and prospects for community pharmacy practice in Switzerland, a confederation of 26 cantons with a population of approximately 7 million, located in the center of Europe. FINDINGS: For the past 10 years, the Swiss Association of Pharmacists has directed an in-depth reform of the profession, with measures such as a system of remuneration based on pharmaceutical cognitive services, a quality care program named QMS-Pharmacy, a postgraduate education program (including specific titles and certificates) and obligatory continuous education, programs of public relations and health promotion, innovative services of managed care, generics substitution, and others. DISCUSSION: The implemented changes in management represent a pharmaceutical care solution for Swiss community pharmacies, which face intense competition and a very liberal policy regarding healthcare organization, relating in particular to the important cantonal autonomy, free establishment of ownership of pharmacies, pharmacy chains, dispensing physicians, chemist shops, mail order, and others. CONCLUSIONS: Community pharmacy in Switzerland is making modernization of its role in public health policy a clear orientation. Priorities for the future include reinforcement of education and academic research in pharmacy practice, demonstration of the added value of pharmacists, integration of new information technologies with pharmacies, and development of new pharmaceutical services for managed care network in collaboration with physicians and other healthcare professionals.     

Personal, organizational, and market level influences on physicians' practice patterns: results of a national survey of primary care physicians

BACKGROUND: One of the principal tenets of managed care is that physicians' clinical decisions can be influenced both to improve the quality and consistency of care and to decrease health care expenditures. Medical decision making, however, remains a complex phenomenon and the most important determinants of physicians' approaches to clinical decision making remain poorly understood. OBJECTIVES: To determine how clinical decisions are associated with individual characteristics, practice setting and organizational characteristics, attributes of the patient population under care, and the market environment. RESEARCH DESIGN: Cross-sectional, nationally representative survey of patient-care physicians. SUBJECTS: Primary care physicians who provide direct patient care at least 20 hours per week. MEASURES: Proportion of physicians who would order a referral, diagnostic test, or treatment for 5 clinical scenarios thought to be representative of discretionary medical decisions. RESULTS: Responses were received from 4,825 primary care physicians who cared for adult patients (Response Rate 65%). The distribution of results for each of the five clinical scenarios demonstrates significant variability both within and between physicians. No evidence was seen of a consistent practice style across the vignettes (eg, "aggressive" or "conservative"). The organizational setting of practice was the most consistent predictor of behavior across all the clinical scenarios, with the exception of back pain, which was minimally related to any of the environmental factors. When compared to physicians in solo practice, physicians in all other practice settings were less likely to order a test or referral or pursue treatment. Practice involvement with managed care and measures of financial influences and administrative strategies associated with managed care were minimally and inconsistently associated with reported physician behaviors. CONCLUSIONS: The ability of managed care to improve the quality and consistency of care while also controlling the costs of care depends on its ability to influence medical decisions. Our findings generally demonstrate that managed care has a weak influence on discretionary medical decisions and that the influence of managed care pales in comparison to personal and practice setting influences.     

Midwifery education today

Today, there are more than 7000 CNMs and CMs in the United States, who attend approximately 9% of American births annually in hospitals, birth centers, and homes. Midwives work in a variety of practice models, including group practices with physicians, HMOs, private practices, rural and urban community health centers, and large managed care organizations. CNMs and CMs also serve as administrators, policy makers, and consultants in international maternal and child health. Midwifery education has come a long way since 1931, when the first education program started. The dedication of CNMs to our clients and the midwifery model of care, as well as these midwifery educational innovations, will continue to support the profession's goals of offering humane, holistic, and safe health care to women and their families.     

Hospitals, nursing, and medicine: the years ahead

Integrated approaches to the delivery of patient care have the potential to do several things to alleviate potential problems resulting from the five changes discussed earlier. They bring physicians into a more active role with the largest group of employees in the hospital (nurses); giving them the opportunity to acquire a better appreciation of the objectives, goals, and constraints of other providers and of the institution as a whole. When nurses and other employees begin to appreciate the constraints placed on physicians by federal regulations and competition, mutual understandings are fostered. They lay a more solid foundation for good professional relationships between hospitals and IPAs and between hospital-based physicians and independent practitioners. They encourage the focus of all providers on quality patient care (at a price the community is willing to afford). They discourage the overlap of expensive services between providers and encourage planned growth for the community. They encourage collaborative practice at the bedside, at committee and board meetings, and throughout the community that can lead to the development of a new model of "health" care as opposed to "disease" care. Finally, they promote human understanding that encourages providers to recognize the appropriate professional (considering all the variables) for each role. Without such efforts, it appears that patient care quality will be the most likely aspect of health care to suffer in the future--a result against which all health care professionals should stridently guard.     

Malignant glioma: coping with a devastating illness.

The diagnosis of a malignant brain tumor can thrust a patient and family onto an emotional roller coaster. This crisis can be better managed with the help of a sensitive interdisciplinary team comprised of nurses, physicians, clinical social workers and other health care professionals. Healthcare personnel can help to provide information, support and coping strategies. Nursing and family support groups enable all involved to survive the personal and professional losses they experience.     

A needs assessment for southern Manitoba physicians for palliative care education

Recent calls for increased palliative care education of physicians and a need to improve the effectiveness of palliative care delivery in rural areas are the stimuli for this study. The needs assessment evaluated educational needs and preferences of physicians practicing in three Regional Health Authorities in southern Manitoba in 2000, as well as semi-structured interviews with health care workers in seven rural communities. Physicians report their knowledge of symptom management issues as adequate, although for other issues in palliative care such as bereavement, psychosocial aspects of dying, and professional issues, they have less confidence. Physicians prefer learning through case studies, lectures, and self-directed learning, in settings close to their community, on the weekend. Qualitative analysis from the semi-structured interviews revealed themes related to the role of physicians in rural palliative care: i) a need for physician education, ii) physician participation within the palliative care team, and iii) physician involvement in patient-centered care.     

Using Medicaid fee-for-service data to develop community health center policy

This article presents an analysis of fee-for-service Medicaid data for King County, Washington. This analysis was conducted using Department of Social and Health Services billing records for patients of the community health centers of Seattle-King County (14 primary care sites), the Seattle-King County Department of Public Health (9 primary care sites), and Harborview Medical Center (a large tertiary facility with a primary care outpatient clinic associated with the University of Washington) from January through June, 1992. The complete billing records of all patients who utilized any one of the 24 sites were made available. These records were used to review utilization patterns and patient costs. The implications for community health centers regarding Medicaid managed care, health care reform, and population-based management are discussed.     

Urban/rural differences in health insurance coverage among people with multiple sclerosis

PURPOSE: To present urban/rural analyses of health insurance coverage among people with multiple sclerosis (MS). This research also combined all survey respondents from each urban/rural area into one group of people with MS in health maintenance organizations (HMOs)/managed care and another group of people with MS who have other health insurance plans to compare any differences in coverage. METHODS: We interviewed 1,518 people with MS living in all 50 states. Survey results were analyzed using SPSS. RESULTS: Most people with MS in each urban/rural area had health insurance coverage (92-95%), with significant urban/rural differences observed in HMO/managed care enrollments. We found no urban/rural differences among people with MS in HMOs/managed care, or among people with MS with other health insurance plans, in satisfaction with coverage of routine care and MS-focused care, or with perceptions of how coverage enables utilization of health services. However, we found that people with MS in HMOs/managed care were more satisfied than people with MS with other health insurance with their coverage of routine care and perceived that their coverage enabled greater utilization of routine care and needed medications. CONCLUSIONS: We found no significant differences in satisfaction with MS-focused care or with perceptions of how well coverage enables utilization of MS-focused care or needed assistive devices between people with MS in HMOs/managed care and people with MS who have other health insurance.     

Urban/rural differences in health insurance coverage among people with multiple sclerosis

Purpose. To present urban/rural analyses of health insurance coverage among people with multiple sclerosis (MS). This research also combined all survey respondents from each urban/rural area into one group of people with MS in health maintenance organizations (HMOs)/managed care and another group of people with MS who have other health insurance plans to compare any differences in coverage.

Methods. We interviewed 1,518 people with MS living in all 50 states. Survey results were analyzed using SPSS.

Results. Most people with MS in each urban/rural area had health insurance coverage (92 – 95%), with significant urban/rural differences observed in HMO/managed care enrollments. We found no urban/rural differences among people with MS in HMOs/managed care, or among people with MS with other health insurance plans, in satisfaction with coverage of routine care and MS-focused care, or with perceptions of how coverage enables utilization of health services. However, we found that people with MS in HMOs/managed care were more satisfied than people with MS with other health insurance with their coverage of routine care and perceived that their coverage enabled greater utilization of routine care and needed medications.

Conclusions. We found no significant differences in satisfaction with MS-focused care or with perceptions of how well coverage enables utilization of MS-focused care or needed assistive devices between people with MS in HMOs/managed care and people with MS who have other health insurance.     

Patient Scenario Identifies Gaps in Breast Cancer Services in a Rural Region

Studies have demonstrated that community-based cancer coalitions can effectively address cancer disparities in rural areas. Scenario plots have been used to assess community needs in health care and public health. The social and medical context of a woman with undetected breast cancer was developed as a patient scenario implemented at a rural cancer coalition meeting to rapidly identify gaps in services. Transportation, fragmentation of cancer care, access to insurance coverage, patient navigation, and survivorship services were identified as gaps in ensuring patient compliance across the continuum of breast cancer care throughout the region. Results will be used to shape coalition priorities.     

Enhancing breast health in rural populations: clinical nurse specialist as the key

Four clinical nurse specialists (CNSs) were funded for a project to increase breast cancer (BC) screening practices and the knowledge of BC risk factors for women in 4 medically underserved rural counties. The goal was to implement a program to increase knowledge of breast health practices, increase access to mammography, establish linkages among CNSs and community organizations, and increase resources for breast health education and screening. Phase I: A training program (focusing on breast health, breast cancer, and screening) was presented to public health nurses from each of the 4 counties. Phase II: Project and public health nurses teamed to provide an education and screening program for rural area women. The program involved making mammograms available at no cost through a mobile mammography unit that was brought to each county. Mammograms and educational programs were provided to 141 women. The project team was clearly able to function as both clinical experts and clinical leaders. The spheres of influence for these 4 CNSs included patient/client (rural women), nursing personnel (county health department nurses), and organization/network (state health department and governmental bodies). This project, based on the Logic Model, can serve as a framework for delivering care in underserved, rural populations.     

Effects of managed care on the length of time that elderly patients spend with physicians during ambulatory visits: National Ambulatory Medical Care Survey

OBJECTIVES: To examine the factors related to the length of time that elderly patients spend with physicians during ambulatory visits and explore specifically the association between managed care and visit duration. DESIGN: Cross-sectional analysis of the 1998 National Ambulatory Medical Care Survey. SUBJECTS: Four thousand nine hundred sixty-four office visits to nonfederally employed physicians by elderly patients who had face-to-face contact with physicians and had complete information on variables related to managed care. MEASURES: Information was collected on the characteristics of patient, physician and clinic, visit duration, reasons for visit, diagnoses, clinical services performed, and medications ordered. Measures of managed care included patient's health maintenance organization (HMO) status, requirement of authorization, capitation, and HMO ownership of the clinic. RESULTS: The mean visit duration was 19.2 minutes for elderly patients (27.0 minutes for new patients and 18.3 minutes for established patients; P <0.001). In bivariate analyses, the patient's HMO status was not associated with visit duration, but office visits for patients seen at clinics owned by HMOs were 4.2 minutes shorter than those seen in other settings (P <0.001). In multivariate analyses with mixed-effect models, HMO-owned clinic was an independent predictor for shorter visit duration, after adjusting for other patient, physician, and clinic characteristics and type of service provided. CONCLUSIONS: The effects of managed care on the duration of ambulatory visits by elderly patients appear to be related to the structure of the managed care plan rather than managed care reimbursement per se.     

Pitfalls in Spinal X-Ray Diagnosis

Local initiative is the key for improved health care in any community, large or small. In a rural area in Washington, staff members of a small hospital became involved in plans to improve health care in their community. They presented their needs to the Washington-Alaska Regional Medical Program. The Regional Advisory Group and the National Advisory Council approved the requests and granted support for postgraduate preceptorships, a coronary care unit, an educational program for laboratory technicians, and a medical television series for physicians.     

Physicians, physicians' assistants, and the social characteristics of patients in southern Appalachia.

A focus on health care delivery systems and the emergence of New Health Practitioners, particularly Physicians' Assistants (PAs), represents one of the more significant nonbiomedical developments in American medicine since World War II. Much discussion about PAs revolves around the kinds of illnesses they are qualified to treat which then permits physicians to concentrate on patients with other types of illnesses. Ignored in this focus on illness characteristics is the possibility that physicians and PAs may treat patients with different social characteristics. That issue is the topic of this paper. Differences between the status characteristics of physician and PA patients are reported for a rural community where PAs and physicians work side by side in the same offices. The relationships observed in this rural community suggest that the higher a patient's socioeconomic status, the more likely (s)he is to be treated by the physician.     

Evaluation of a new mental health liaison role in a rural health centre in Rocky Mountain House,Alberta: A Canadian story

This paper describes the evaluation of a mental health liaison (MHL) role in a rural community in Alberta, Canada. The role provides advocacy, education, indirect and direct client intervention, and follow up. It was developed to eliminate gaps in mental health care and build collaborative cultures between the local hospital, physicians' offices, mental health clinics, and community agencies. Obtaining stakeholder feedback was an important step in assessing initial service impact while providing directions for role refinement and future programme development. A total of 116 questionnaires were distributed to physicians, hospital staff, and community mental health assessing stakeholder perception relating to various functions of the MHL. A 50% (n = 58) response rate was achieved with broad representation from different partners, including 75% of local physicians. The majority of respondents positively perceived the roles, functions, and impact of the MHL, including relationship development across the hospital community, improved access to services, and perceived improved client outcomes. The results reinforced that the MHL service meets a previously unmet need in this rural setting. Findings are being used to refine roles, provide local learning and resource development, understand issues relating to programme development in other areas, and develop client level outcomes relating to the services delivered.