Audit of consultant physicians' reply letters for referrals to clinics in a tertiary teaching hospital

Background: Doctors referring patients to consultant physicians seek reply letters which both educate and assist in ongoing patient management. Highly desirable attributes in specialist letters include clearly stated and justified: (i) diagnostic formulations, (ii) management regimens, (iii) use of clinical investigations, (iv) prog-nostic statements, (v) contingency plans and (vi) follow-up arrangements. Aim: To explicitly evaluate the quality of reply letters for new patients referred to clinics at a tertiary teaching hospital. Methods: Letters were sampled from outpatient clinics of 10 different medical specialties at Princess Alexandra Hospital in Brisbane, Australia. Reply letters for new patient referrals between 1 August 2000 and 31 October 2000 were retrieved, from which data were abstracted to calculate the proportion of letters satisfying prespecified quality attributes. Results: Of 297 new patient referrals, reply letters were retrieved for 204 (69%). Of these, 147 (72%) referrals were accompanied by a referral letter, mostly (113/147; 77%) from general practitioners. For 120 referrals involving diagnostic issues, 69 (56%) letters stated a diagnostic formulation. Of 114 letters recommending further clinical investigations, 61 (53%) described a rationale for such testing. In 125 cases where therapy was a key issue, 83 (66%) letters recommended changes to current treatment for which reasons were specified in 46 (55%) cases, and contingency plans provided in 13 (16%). Prognosis was mentioned in only 18 (9%) cases. Follow-up arrangements were detailed in 123 (60%) letters. Assessments of patient understanding and likely adherence to therapy were stated in less than 15% of -letters. Conclusions: Opportunities exist for improving quality of consultant physicians' reply letters in terms of greater use of problem lists, contingency plans, prognostic statements and patient-centred assessments, as well as more frequent enunciation of consultants' reasoning behind requests for further tests and changes to current management. Use of structured letter templates may facilitate more consistent inclusion of key information to referring doctors.

Effectiveness of a mutual support group for families of patients with schizophrenia

Aim. This paper reports a study to examine the effectiveness of a 12-session mutual support group for Chinese families caring for a relative with schizophrenia compared with a psycho-educational group and routine family support services in Hong Kong. Background. Schizophrenia is a disruptive and distressing illness for patients and their families. With the current trend of community care for mental illness, there is evidence that family intervention reduces patient relapse and re-hospitalization, satisfies the health needs of families and enhances their coping capabilities. Methods. A randomized controlled trial was conducted from May 2002 to June 2003 with 96 Chinese families of a relative with schizophrenia selected from two psychiatric outpatient clinics in Hong Kong. Families were randomly assigned to receive mutual support (n = 32), psycho-education (n = 33) or standard care only (n = 31). The interventions were delivered at outpatient clinics over a 6-month period. Pre- and post- (1 week and 6 months) testing took place and families' functioning, mental health service utilization, patients' level of functioning and duration of re-hospitalization were measured. Results. At both post-test periods, family caregivers and patients in the mutual support group reported statistically significant improvements on family and patients' level of functioning, when compared with their counterparts in the psycho-education and standard care groups. Conclusions. The findings support the use of mutual support groups as an effective modality of family intervention in a Chinese population caring for a family member with schizophrenia to improve both family and patient functioning.

Quality of Life in Chinese elderly people with depression

Background Depression is the most prevalent functional mental disorder of later life. It is estimated that about 5% of the elderly population of Hong Kong are suffering from depression. Aim To investigate the self-rated quality of life of community-dwelling elderly people diagnosed with depression, and to examine the relationships between quality of life and mental, physical health, functional status and social support. Methods and results A cross-sectional descriptive survey was conducted in psychiatric outpatient clinics. A convenience sample of 80 Chinese elderly people with a diagnosis of depressive disorder was recruited. Perception of quality of life was measured by the Hong Kong Chinese World Health Organization Quality of Life Scale-Brief Version. Participants' mental status, functional abilities, physical health condition, and social support status were assessed. Sixty-one (76.3%) participants were female. They were least satisfied with meaningfulness of life, life enjoyment, concentration and thinking, energy and work capacity. Functional abilities had a positive association with participants' perceived quality of life, level of depression and number of physical health conditions had a negative association. Participants had low ratings of quality of life when compared with healthy persons and persons with chronic physical problems. Findings are discussed in light of the socio-cultural environment in Hong Kong. Conclusion Comprehensive treatment and better control of depression, including different modes of medical and psychosocial intervention, could help to improve participants' perception of quality of life. A longitudinal study with a larger sample with various levels of depression and socio-demographic characteristics is recommended. Copyright © 2006 John Wiley & Sons, Ltd.

Randomised controlled trial of telemedicine for new neurological outpatient referrals

Objective-To test the hypothesis that telemedicine for new patient referrals to neurological outpatients is as efficient and acceptable as conventional face to face consultation. Methods-A randomised controlled trial between two groups: face to face (FF) and telemedicine (TM). This study was carried out between a neurological centre and outlying clinics at two distant hospitals linked by identical medium cost commercial interactive video conferencing equipment with ISDN lines transmitting information at 384 kbits/s. The same two neurologists carried out both arms of the study. Of the 168 patients who were suitable for the study, 86 were randomised into the telemedicine group and 82 into the face to face group. Outcome measures were (I) consultation process: (a) number of investigations; (b) number of drugs prescribed; (c) number of patient reviews and (2) patient satisfaction: (a) confidence in consultation; (b) technical aspects of consultation; (c) aspects surrounding confidentiality. Diagnostic categories were also measured to check equivalence between the groups: these were structural neurological, structural non-neurological, nonstructural, and uncertain. Results-Diagnostic categories were similar (p>0.5) between the two groups. Patients in the telemedicine group had significantly more investigations (p=0.001). There was no difference in the number of drugs prescribed (p>0.5). Patients were generally satisfied with both types of consultation process except for concerns about confidentiality and embarrassment in the telemedicine group (p=0.017 and p=0.005 respectively). Conclusion-Telemedicine for new neurological outpatients is possible and feasible but generates more investigations and is less well accepted than face to face examination.

Predictors of genital warts among women attending two family planning clinics

Objectives: To establish the prevalence and predictors of genital warts among healthy women presenting for contraceptive advice at two family planning clinics, one in a major Australian city and one in a country town in the same state. Methods: Consecutive consenting attendees (n = 1218)at two family planning clinics in Queensland completed a questionnaire and were examined for genital warts. Results: The point prevalence of visible genital warts was 3.3 per cent in the city clinic and 14.4 per cent in the country town. For half of these clients a finding of warts was unexpected, in that the client was unaware of their presence and presentation to the family planning clinic was not specifically for advice about sexually transmitted infections. The major predictor of a finding of warts was client age, with the highest prevalence in 20- to 25-year-olds. Warts were also commoner amongst smokers in the country town but not in Brisbane. However, no analysed sociodemographic variable predicted a finding of warts of which the client was not aware. Conclusions: Genital warts are common among young women presenting for contraceptive advice. Such women are often unaware that they have warts. Examination for genital warts should be a part of any routine examination of sexually active women, and medical practitioners should be aware of appropriate advice for patients who are found to have genital warts on routine examination.

The effect of spatial definition on the allocation of clients to screening clinics

We compared four strategies for inviting 91,456 women aged 50-69 years to one of six clinics for mammography screening and 40,142 men aged 60-79 years to one of 10 clinics for abdominal aortic aneurysm (AAA) screening. The strategies were invitation to the clinic nearest to the client and invitation to the clinic nearest to the client's area of residence defined by census small area, postcode and local government area. For each strategy we calculated the expected demand at each clinic and the travel distances for clients. We found that when women were allocated to mammography clinics on the basis of the local government area instead of their individual address, expected demand at one clinic increased by 60%, and 19% of clients were invited to attend a more remote clinic, entailing 99,000 km of additional travel. Similar results were obtained for men allocated to AAA clinics by their postcode of residence instead of their individual address: 55% difference in expected demand, 13% to a more remote clinic and 60,000 km of extra travel. Allocation on the basis of small areas did not show such great differences, except for travel distance, which was about 5% higher for each clinic type. We recommend that allocation of clients to screening clinics be made according to residential address, that assessment of the location of clinics be based on distances between residences and nearest clinic, but that planning new locations for clinics be aided with spatial analysis tools using small area demographic and social data. (C) 1997 Elsevier Science Ltd.

Adherence with naltrexone prescription advice in hospital outpatient alcohol rehabilitation programme

Background: The anti-craving drug, naltrexone, is used as a pharmacotherapeutic adjunct in the treatment of alcohol dependence. In addictive disorders, compliance issues remain central. There are limited data on compliance with naltrexone treatment regimens within formalized rehabilitation programs and even less data that identifies factors that have an impact on this. Objective: To study patient adherence to naltrexone medication regimens and examine whether patients' reported pre-treatment alcohol use, dependence severity and measures of psychological health are predictive of medication compliance. Method: Fifty outpatients meeting DSM IV criteria for alcohol dependence enrolled in 12-week rehabilitation programme. This included cognitive behavioural therapy (CBT) and naltrexone, 50 mg orally daily. Measures included: pharmacy prescription pick-up including number of tablets dispensed, programme attendance and patient pre-treatment alcohol use variables. Measures of psychological health included somatic symptoms, anxiety, social dysfunction and depression as measured by the General Health Questionnaire (GHQ-28). Results: Classifying the sample into compliant (greater than or equal to 90% medication pick-up) and less compliant groups, 66% of subjects were naltrexone-compliant. Pre-treatment alcohol use variables were not predictive of compliance. Although social dysfunction and depression tended towards poorer prescription filling, measures of psychological distress (GHQ-28) did not identify factors predictive of medication non-compliance. One patient withdrew from treatment because of naltrexone-induced dysphoria. Conclusion: Patients with alcohol dependence demonstrated high levels of anti-craving medication compliance, good rehabilitation programme participation and favourable outcomes. Naltrexone was well tolerated. Medication compliance in this study group compared well with those of other hospital populations with chronic disorders. Factors predictive of anti-craving medication compliance in alcohol dependence require further study.

Outpatient cognitive behavioural therapy programme for alcohol dependence impact of naltrexone use on outcome

Objective: Cognitive-behavioural therapy (CBT) has been effectively used in the treatment of alcohol dependence. Clinical studies report that the anticraving drug naltrexone, is a useful adjunct to treatment. Currently, few data are available on the impact of adding this medication to programmes in more typical, outpatient, and rehabilitation settings. The objective of this study was to examine the impact on outcome of adding naltrexone to an established outpatient alcohol rehabilitation program which employed CBT. Method: Fifty patients participated in an established 12-week, outpatient, 'contract'-based alcohol abstinence programme which employed CBT. They also received naltrexone 50 mg orally daily (CBT + naltrexone). Outcomes were compared with 50 historical, matched controls, all of whom participated in the same programme without an anticraving medication (CBT alone). All patients met DSM-IV criteria for alcohol dependence. Results: Programme attendance across the eight treatment sessions was lower in the CBT alone group (p < 0.001). Relapse to alcohol use occurred sooner and more frequently in the CBT alone group (p < 0.001). Rehabilitation programme completion at 12 weeks was 88% (CBT + naltrexone) compared with 36% for (CBT alone) (p < 0.001). Alcohol abstinence at 12 weeks was 76% (CBT + naltrexone) compared with 18% (CBT alone) (p < 0.001). Conclusion: When employing the same outpatient rehabilitation programme and comparing outcomes using matched historical controls, the addition of naltrexone substantially improves programme attendance, programme completion and reported alcohol abstinence. In a typical outpatient programme, naltrexone addition was associated with significantly improved programme participation, better outcomes and was well tolerated.

Cost implications of outpatient teleneurology

A randomized controlled trial was conducted to compare the costs of realtime teleneurology with the cost of conventional neurological care. Two district hospitals in Northern Ireland were equipped with videoconferencing units and were connected to the regional neurological centre by ISDN at 384 kbit/s. Of 168 patients randomized to the study, 141 kept their appointments (76 male, 65 female). Sixty-five patients were randomized to a conventional consultation while 76 were randomized to a teleconsultation. The average age was 44 years of those seen conventionally and 42 years of those seen by telemedicine. The groups had similar diagnoses. The telemedicine group required more investigations and reviews than the conventional group. The average cost of the conventional consultation was pound 49 compared with pound 72 for the teleconsultation. Realtime teleneurology was not as cost-effective as conventional care.

Making decisions about treatment for localized prostate cancer

Objective To describe the decision-making processes used by men diagnosed with localized prostate cancer who were considering treatment. Patients and methods Men newly diagnosed with localized prostate cancer from outpatient urology clinics and urologist's private practices were approached before treatment. Their decision-making processes and information-seeking behaviour was assessed; demographic information was also obtained. Results Of 119 men approached, 108 (90%) were interviewed; 91% reported non-systematic decision processes, with deferral to the doctor, positive and negative recollections of others' cancer experiences, and the pre-existing belief that surgery is a better cancer treatment being most common. For systematic information processing the mean (SD, range) number of items considered was 4.19 (2.28, 0-11), with 57% of men considering four or fewer treatment/medical aspects of prostate cancer. Men most commonly considered cancer stage (59%), urinary incontinence (55%) and impotence (51%) after surgery, and low overall mortality (45%). Uncertainty about probabilities for cure was reported by 43% of men and fear of cancer spread by 37%. Men also described uncertainty about the probabilities of side-effects (27%), decisional uncertainty (25%) and anticipated decisional regret (18%). Overall, 73% of men sought information about prostate cancer from external sources, most commonly the Internet, followed by family and friends. Conclusions In general, men did not use information about medical treatments comprehensively or systematically when making treatment decisions, and their processing of medical information was biased by their previous beliefs about cancer and health. These findings have implications for the provision of informational and decisional support to men considering prostate cancer treatment.

At-risk children: A demographic analysis of the children of clients attending mental health community clinics

Children of parents with mental illness have an increased risk of psychological problems. The aim of this study was to identify the demographic characteristics of dependent children of adults presenting at mental health clinics in Western Australia. A survey of clients who attended the clinics indicated that half reported having had children. Of these, 21% had a primary diagnosis of schizophrenia. Although schizophrenia was the most common illness, there were almost seven times more children living with a parent with a primary diagnosis of depression than schizophrenia. Recommendations include that children of clients with mental illness be included as part of a wider client focus.

Utilisation of outpatient cardiac rehabilitation in Queensland

Objectives: To determine patient participation rates in outpatient cardiac rehabilitation (OCR) programs; ascertain the barriers to participation; and evaluate the quality of OCR programs. Design and setting: Retrospective cohort study of patient separations from selected public and private Queensland hospitals; questionnaire survey of hospitals and all registered OCR programs. Participants: Patients discharged with cardiac diagnoses between 1 July 1999 and 30 June 2000 from 31 hospitals (24 public; 7 private). Main outcome measures: Rates of referral of hospitalised patients to OCR programs; rates of program attendance and completion; barriers to OCR referral and attendance. Results: 15186 patients were discharged with cardiac diagnoses from participating hospitals, of whom 4346 (29%) were referred to an OCR program after discharge, compared with an estimated 59% (8895/15 186) of patients who were eligible for such a program. Proportionately more patients were referred from secondary (38% [1720/4500]) and private (52% [2116/4031]; P < 0.001) hospitals than from tertiary (25% [2626/10 686]) and public (20% [2230/11 155]) hospitals. Patients undergoing coronary revascularisation procedures comprised 35% of discharges, but accounted for 56% of all program attendances. Fewer than a third of all referred patients completed OCR programs, and only 39% of available OCR program places were fully utilised. Catchment populations of programs with unused places had excess coronary mortality. Conclusion: There is significant underutilisation of facility-based OCR programs in Queensland. Procedures are required for identifying and referring eligible patients to existing programs and improving program compliance. Alternative OCR models are also required.