Effectiveness of screening for risk of medical emergencies in the elderly

Study objective: UK government policy mandates the introduction of 'intermediate care services' to reduce emergency admissions to hospital from the population aged 75 years or more. We evaluated one of these initiatives-the Keep Well At Home (KWAH) Project-in a West London Primary Care Trust. Design: KWAH involves a two-phase screening process, including a home visit by a community nurse. We employed cohort methods to determine whether KWAH resulted in fewer emergency attendances and admissions to hospital in the target population, from October 1999 to December 2002. Results: estimated levels of coverage in the two phases of screening were 61 and 32%, respectively. The project had not maintained records of which additional health and social care services had been delivered following screening. The rates of emergency admissions to hospital in the 9 months before screening were similar in practices that did and did not join the project (rate ratio (RR) = 1.05; 95% CI 0.95-1.17), suggesting absence of volunteer bias. Over the first 37 months of the project, there was no significant impact on either attendances at Accident & Emergency departments (RR = 1.02; 95% CI 0.97-1.06) or emergency admissions of elderly patients (RR = 0.98; 95% CI 0.93-1.05). Conclusion: the KWAH Project has been ineffective in reducing emergency admissions among the elderly. Significant questions arise in relation to selection of the screening instruments, practicality of achieving higher coverage of the eligible population, and creation of a new postcode lottery.

An e-health needs assessment of medical residents in Cameroon

Medical residents from Yaounde I University in Cameroon are required to spend periods of time in rural or remote locations to complete their training. To determine if e-health might lessen their isolation and enhance patient care, a needs assessment of the residents was performed using a brief questionnaire (five items) about the situation in which residents found themselves outside their medical school environment. We gave the questionnaires to 45 residents. Seventeen questionnaires had been returned at the time of the site visit, a response rate of 38%. Most residents indicated that the ability to contact a mentor would have either made them feel more confident (16, or 94%) or altered their handling of recent cases (15, or 88%). All residents had access to a mobile phone, and many (11, or 65%) had used it to contact a medical colleague for guidance. A low-cost and technologically simple telemedicine solution that maximized use of mobile phone capability, provided access to medical and health-care information, and permitted exchange of images would be an appropriate response to the identified needs.

After hours medical ward duties in a teaching hospital

In many Australian hospitals a medical officer is available for urgent review of in-patients outside normal working hours. Current practice in nurse-initiated requests for medical officer involvement out of hours may adversely affect patient outcome as well as medical and nursing resource use at these times. Of 10 523 nurse-initiated requests for out-of-hours review recorded by medical officers at our hospital in 2002-2003, the most frequent reasons for the requests were medication review, IV fluid orders, IV resite, venesection and pathology review, none of which are related to acute changes in clinical condition. Requests for routine review of medication and fluid orders were found to be rarely essential and often inappropriate. Medical officer activity was highest before midnight and least after midnight, suggesting most requests are fulfilled in the evening. Several strategies to reduce inappropriate out-of-hours requests were identified. Routine tasks could be completed by primary treating unit staff before going off-duty. IV cannulation and venesection may be performed by appropriately trained phlebotomists or skilled advanced practice nursing staff. Meticulous ordering of 'as required' analgesia and night sedation would reduce unnecessary requests. Clinical protocols for nurse-initiated adjustment of drugs with variable dosing may also decrease inefficiencies. This would leave the ward cover medical officers more available for their primary function of urgent patient review.

Carvedilol reduces the costs of medical care in severe heart failure: An economic analysis of the COPERNICUS study applied to the United Kingdom

Background: The aim of this study was to determine the effects of carvedilol on the costs related to the treatment of severe chronic heart failure (CHF). Methods: Costs for the treatment for heart failure within the National Health Service (NHS) in the United Kingdom (UK) were applied to resource utilisation data prospectively collected in all patients randomized into the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study. Unit-specific, per them (hospital bed day) costs were used to calculate expenditures due to hospitalizations. We also included costs of carvedilol treatment, general practitioner surgery/office visits, hospital out-patient clinic visits and nursing home care based on estimates derived from validated patterns of clinical practice in the UK. Results: The estimated cost of carvedilol therapy and related ambulatory care for the 1156 patients assigned to active treatment was 530,771 pound (44.89 pound per patient/month of follow-up). However, patients assigned to carvedilol were hospitalised less often and accumulated fewer and less expensive days of admission. Consequently, the total estimated cost of hospital care was 3.49 pound million in the carvedilol group compared with 4.24 pound million for the 1133 patients in the placebo arm. The cost of post-discharge care was also less in the carvedilol than in the placebo group (479,200 pound vs. 548,300) pound. Overall, the cost per patient treated in the carvedilol group was 3948 pound compared to 4279 pound in the placebo group. This equated to a cost of 385.98 pound vs. 434.18 pound, respectively, per patient/month of follow-up: an 11.1% reduction in health care costs in favour of carvedilol. Conclusions: These findings suggest that not only can carvedilol treatment increase survival and reduce hospital admissions in patients with severe CHF but that it can also cut costs in the process.

Reliability and validity of the medical outcomes study social support survey (Chinese version)

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