Does continuity of care with a family physician reduce hospitalizations among older adults?

OBJECTIVE: To examine the relation between continuity of primary care and hospitalizations. METHODS: Survey data from a representative sample of older adults aged 67 or over living in the province of Manitoba (n = 1863) were linked to administrative data, which provide complete records of physician visits and hospitalizations. A visit-based measure of continuity of care was derived using a majority-of-care definition, whereby individuals who made 75% of all their visits to family physicians (FPs) to the same FP were classified as having high continuity of care, and those with less than 75% of their visits to the same FP as having low continuity of care. Whether individuals were hospitalized (for either ambulatory care-sensitive conditions or all conditions) was also determined from administrative records. RESULTS: High continuity of care was associated with reduced odds of ambulatory care-sensitive hospitalizations (adjusted odds ratio = 0.67, confidence interval 0.51-0.90) controlling for demographic and self-reported, health-related measures. It was not related to hospitalizations for all conditions, however. CONCLUSIONS: The study highlights the importance of continuity of primary care in reducing potentially avoidable hospitalizations.     

Does a family physician who offers colposcopy and LEEP need to refer patients to a gynecologist?

BACKGROUND: Many family physicians perform colposcopy and provide treatment when biopsy reveals dysplasia. Before the adoption of loop electrical excision procedure (LEEP) gynecologic referral following colposcopy was required for a small percentage of women--most commonly for cold cone procedures. The use of LEEP and LEEP cones may obviate the need for cold conization, so we sought to assess the pattern of gynecologic referral in the practice of family physicians skilled in this procedure. METHODS: We reviewed the referral practices of a family medicine residency practice that routinely provides LEEP for biopsy-proven cervical intraepithelial neoplasia requiring treatment. Colposcopy and, when indicated, LEEP were performed primarily by the senior author or by residents under close faculty supervision. The computerized clinic log was reviewed for all patients from its 1993 inception through November 1999, and all treatment decisions were evaluated. RESULTS: During the study period, 283 women were seen in the clinic, and 26 individuals (9%) were referred by the family physician colposcopist to a consulting gynecologist. CONCLUSIONS: Despite use of LEEP, a minority of patients continues to need gynecologic referral. Large acetowhite lesions extending onto the vaginal fornix accounted for the majority of referrals, and some patients were referred exclusively for cold cone biopsy. Although LEEP can allow family physicians to manage cases previously requiring referral, we urge that this procedure be employed only by those with the technical and decision-making skills required for safe and effective treatment.     

Health visiting and public health: back to our roots or a new branch?

The term 'public health nursing' has been introduced within the last decade into the UK without being adequately defined. In consequence, confusion has arisen over the use of the term 'public health' in relation to health visiting. It is not yet clear whether the introduction of the term 'public health nursing' into the UK is a positive step for health visiting, or if it threatens its core functions. The historical developments of the public health movement and health visiting were traced, in particular, the main strands that have led to current confusion over role identity. Analysis of the literature led to one suggestion as to the nature of the public health role for health visitors. This was examined within a social policy framework in order to understand its relevance to current NHS practice. Finally, the contemporary link between health visiting and public health is explored in order to assess whether the public health role represents a new development within health visiting, or an attempt to rediscover mainstream support from public health departments.     

Does use of tobacco or alcohol contribute to impoverishment from hospitalization costs in India?

The study investigates the association between tobacco and alcohol use, and the potential risk of impoverishment from borrowing and distress selling of assets for meeting costs of hospitalization in India. Data from the fifty-second round of the National Sample Survey, a representative survey of 120,942 households across India, were used to investigate the likelihood and the levels of borrowing and distress selling of assets to cover hospitalization expenditures among regular users of tobacco and/or alcohol, non-users from households where there was use, and non-users from households with no use. The data were analyzed by bivariate comparisons and multivariate logistic and ordinary least square regression. The study found a higher risk of borrowing/distress selling during hospitalization for individuals who use tobacco (OR 1.35, p<0.05), who were non-users but belong to households that use tobacco (OR 1.38, p<0.05), and non-users from households that use both tobacco and alcohol (OR 1.51, p<0.05), even after controlling for socio-economic and demographic factors. The same groups also met a higher percentage of hospitalization expenditures through borrowing/distress selling of assets. The adjusted population-attributable risk proportion of borrowing/distress selling to meet hospital expenditures for tobacco and alcohol use was 16%. The study suggests that there is an association between use of tobacco and alcohol, and impoverishment through borrowing and distress selling of assets due to costs of hospitalization. While reduction of poverty is the overarching goal of developing countries and multilateral development organizations, very little is mentioned about control of tobacco and alcohol in the framework of development. It might be necessary to include strategies for control of tobacco and alcohol in the larger framework of poverty reduction.     

Are differences between graduates and undergraduates in a medical course due to age or prior degree?

BACKGROUND: The number of medical programmes targeted at graduates is increasing and there are reports of beneficial outcomes. However, many new graduate medical schools have simultaneously changed their admission criteria and curricula. This study aimed to determine whether there were differences between graduates and undergraduates on the same medical course and to establish which differences might be due to having a prior degree, the course itself or age at entry to medical school. METHODS: A questionnaire-based survey was administered to all students in Years 2-5. It included the Study Process Questionnaire, the Achievement Motivation Profile and Likert scale questions on career. RESULTS: Questionnaires were completed by 587 students (response rate 80.3%), of whom 143 had a prior degree. Whilst having a prior degree was associated with many outcomes, for most this disappeared, and the overall predictive ability of the model improved when age was included. Age at entry to medical school brought certainty and motivation about career choice, a prior degree had some effect on approaches to studying and co-operativeness, while the course itself had effects on most outcomes, some of which were positive and some negative. CONCLUSION: Graduates bring a distinct quality to a course but many of these relate to a student's age. Older age at entry may be more important than having a prior degree.     

‘Key to a good life’ or just a bad investment? How do carers of children view and value education in the context of high HIV and AIDS?

Abstract

In the face of a generalized Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Virus (AIDS) epidemic in Southern Africa, children's education is viewed increasingly as a key area of concern as well as a potential opportunity for HIV intervention. However, the relationship between HIV and AIDS and education is a complex one, as the epidemic may influence educational indicators negatively through multiple pathways. This paper focuses upon one of these potential pathways: caregivers' attitudes to and perceptions of formal education. We argue that this area has not been afforded adequate attention among researchers and practitioners in Southern Africa despite evidence, from both the developed and developing world, that parental attitudes are important influencers of children's attitudes to education and educational outcomes. A review of recent empirical literature, and findings of a 2006–07 exploratory study we conducted across three sites in Southern Africa, suggest that economic factors or considerations – rather than health and objective life expectancy – are central in influencing the value caregivers attribute to children's formal education, even in a context of generalized HIV/AIDS. Further integrated qualitative and quantitative investigation is clearly needed in our region to explore determinants of parental attitudes to education among communities highly affected by the epidemic, and how these attitudes affect education-related decisions and outcomes. Interventions have a greater possibility of succeeding if they aim to support income-generating opportunities and include efforts to bridge schooling and health education with economic opportunities. Moreover, conditional transfers and school-based interventions or services are more likely to be effective at ensuring school attendance than unconditional transfers, particularly where the value caregivers attribute to education is low.     

Does Vitamin D Sufficiency Equate to a Single Serum 25-Hydroxyvitamin D Level or Are Different Levels Required for Non-Skeletal Diseases?

Objective: Clarify the concept of vitamin D sufficiency, the relationship between efficacy and vitamin D status and the role of Vitamin D supplementation in the management of non-skeletal diseases. We outline reasons for anticipating different serum vitamin D levels are required for different diseases. Method: Review the literature for evidence of efficacy of supplementation and minimum effective 25-hydroxyvitamin D (25-OHD) levels in non-skeletal disease. Results: Evidence of efficacy of vitamin supplementation is graded according to levels of evidence. Minimum effective serum 25-OHD levels are lower for skeletal disease, e.g., rickets (25 nmol/L), osteoporosis and fractures (50 nmol/L), than for premature mortality (75 nmol/L) or non-skeletal diseases, e.g., depression (75 nmol/L), diabetes and cardiovascular disease (80 nmol/L), falls and respiratory infections (95 nmol/L) and cancer (100 nmol/L). Conclusions: Evidence for the efficacy of vitamin D supplementation at serum 25-OHD levels ranging from 25 to 100 nmol/L has been obtained from trials with vitamin D interventions that change vitamin D status by increasing serum 25-OHD to a level consistent with sufficiency for that disease. This evidence supports the hypothesis that just as vitamin D metabolism is tissue dependent, so the serum levels of 25-OHD signifying deficiency or sufficiency are disease dependent.