The experiences and perceptions of unit managers in facilitating oral health in adults with intellectual disability

This qualitative research investigated the experiences and perceptions of unit managers regarding their involvement with oral health management of adults with intellectual disability. Semi-structured individual interviews were conducted with eight participants working in four different area offices of a metropolitan disability service, whose experience as unit managers ranged from 1 to 17 years. Key themes identified in the interview data focused on unit managers' views of the oral health of this group, the support roles involved in the oral health of adults with intellectual disability, the priority of oral health, the experiences of the participants within the oral health system, and the strategies for supporting adults with intellectual disability in oral health management. Implications of the findings included the need to improve education for all persons involved in the oral health of adults with intellectual disability, to encourage a collaborative approach to oral health by workers within accommodation support services and the oral health system, and to enable adults with intellectual disability to maximally participate in their own oral health management.

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.

Factors influencing PRN medication use in nursing homes

Objective: To identify determinants of PRN ( as needed) drug use in nursing homes. Decisions about the use of these medications are made expressly by nursing home staff when general medical practitioners (GPs) prescribe medications for PRN use. Method: Cross-sectional drug use data were collected during a 7-day window from 13 Australian nursing homes. Information was collected on the size, staffing-mix, number of visiting GPs, number of medication rounds, and mortality rates in each nursing home. Resident specific measures collected included age, gender, length of stay, recent hospitalisation and care needs. Main outcome measures: The number of PRN orders prescribed per resident and the number of PRN doses given per week averaged over the number of PRN medications given at all in the seven-day period. Results: Approximately 35% of medications were prescribed for PRN use. Higher PRN use was found for residents with the lower care needs, recent hospitalisation and more frequent doses of regularly scheduled medications. With increasing length of stay, PRN medication orders initially increased then declined but the number of doses given declined from admission. While some resident-specific characteristics did influence PRN drug use, the key determinant for PRN medication orders was the specific nursing home in which a resident lived. Resident age and gender were not determinants of PRN drug use. Conclusion: The determinants of PRN drug use suggest that interventions to optimize PRN medications should target the care of individual residents, prescribing and the nursing home processes and policies that govern PRN drug use.

Optimising care of acute coronary syndromes in three Australian hospitals

Objective. To improve quality of in-hospital care of patients with acute coronary syndromes using a multifaceted quality improvement program. Design. Prospective, before and after study of the effects of quality improvement interventions between October 2000 and August 2002. Quality of care of patients admitted between 1 October 2000 and 16 April 2001 (baseline) was compared with that of those admitted between 15 February 2002 and 31 August 2002 (post-intervention). Setting. Three teaching hospitals in Brisbane, Australia. Study participants. Consecutive patients (n = 1594) admitted to hospital with acute coronary syndrome [mean age 68 years (SD 14 years); 65% males]. Interventions. Clinical guidelines, reminder tools, and educational interventions; 6-monthly performance feedback; pharmacist-mediated patient education program; and facilitation of multidisciplinary review of work practices. Main outcome measures. Changes in key quality indicators relating to timing of electrocardiogram (ECG) and thrombolysis in emergency departments, serum lipid measurement, prescription of adjunctive drugs, and secondary prevention. Results. Comparing post-intervention with baseline patients, increases occurred in the proportions of eligible patients: (i) undergoing timely ECG (70% versus 61%; P = 0.04); (ii) prescribed angiotensin-converting enzyme inhibitors (70% versus 60%; P = 0.002) and lipid-lowering agents (77% versus 68%; P = 0.005); (iii) receiving cardiac counselling in hospital (57% versus 48%; P = 0.009); and (iv) referred to cardiac rehabilitation (17% versus 8%; P < 0.001). Conclusions. Multifaceted approaches can improve care processes for patients hospitalized with acute coronary syndromes. Care processes under direct clinician control changed more quickly than those reliant on complex system factors. Identifying and overcoming organizational impediments to quality improvement deserves greater attention.

Medication management reviews for people from the former Yugoslavia now resident in Australia

Aim: The objective of this prospective study was to conduct medication management reviews (MMR) in people from a non-English speaking background (NESB) (Bosnian/Serbian/ Croatian, from former Yugoslavia, currently residing in Australia) in their native language in order to identify medication-related problems (needs analysis) and implement appropriate therapeutic interventions, in collaboration with their general practitioners (GPs). Methods: Twenty-five participants entered the study. Each was interviewed and medication-related issues were identified by the health care team. Results: Various interventions (over 150 for the whole group, an average of 6 per participant), based on actual and potentia medication-related problems, were designed to improve the use of medicines. The MMRs introduced effective changes into the participants' health care. Psychological (e.g., feeling depressed) and sociological factors (e.g., costs of medicines, not understanding labels written in English) were identified having significant impacts on medication management. Conclusions: These data confirmed there are avoidable medication-related problems in people from a NESB. GPs and pharmacists working in health care teams with a trained interpreter could greatly improve medication use through regular review and a team approach to problem identification and solving.

The effect of bandwidth on the quality of transmitted pediatric echocardiograms

Background: Remote access to pediatric cardiology diagnostic services is enabled by real-time transmission of echocardiographic images. Several transmission bandwidths have been used but there has been little analysis of image quality provided by different bandwidths. We designed a study of the quality of transmitted images at various bandwidths. Methods: Two echocardiographers viewed randomly a series of 13 recorded pediatric echocardiographic images either directly or after transmission using 1 of 4 bandwidths: 256; 384; 512; or 768 kbps. An image clarity scoring scale was used to assess image quality of cardiac structures. Results: Measurable differences were found in image quality with different transmission bandwidths; 512 kbps was the minimum for consistently clear imaging of all cardiac structures examined. Conclusion: Bandwidth greater than 512 kbps confers sharper images subjectively although this could not be quantified by our methods.

Building family/general practice research capacity

To promote the range of interventions for building family/general practice (family medicine) research capacity, we describe successful international examples. Such examples of interventions that build research capacity focus on diseases and illness research, as well as process research; monitor the output of research in family/general practice (family medicine); increase the number of family medicine research journals; encourage and enable research skills acquisition (including making it part of professional training); strengthen the academic base; and promote research networks and collaborations. The responsibility for these interventions lies with the government, colleges and academies, and universities. There are exciting and varied methods of building research capacity in family medicine.

A feasibility study of email communication between the patient's family and the specialist burns team

We investigated whether the parents of burns patients could capture suitable clinical images with a digital camera and add the necessary text information to enable the paediatric burns team to provide follow-up care via email. Four families were involved in the study, each of whom sent regular email consultations for six months. The results were very encouraging. The burns team felt confident that the clinical information in 30 of the 32 email messages (94%) they received was accurate, although in I I of these 30 cases (37%) they stated that there was room for improvement (the quality was nonetheless adequate for clinical decision making). The study also showed that low-resolution images (average size 37 kByte) were satisfactory for diagnosis. Families were able to participate in the service without intensive training and support. The user survey showed that all four families found it easy and convenient to take the digital photographs and to participate in the study. The results suggest that the technique has potential as a low-cost telemedicine service in burns follow-up, and that it requires only modest investment in equipment, training and support.

Prospective case review of a global e-health system for doctors in developing countries

The Swinfen Charitable Trust has managed email consultations for doctors in developing countries since 1999. The process was handled manually for the first three years and then subsequently using an automatic message-handling system. We conducted a prospective review of email consultations between referring doctors and consulting specialists during six months of automatic operation (December 2003 to May 2004). During the study period 125 consultations took place. These concerned a wide range of specialties (e.g. orthopaedics 17%, dermatology 16%, obstetrics and gynaecology 11%, radiology 10%). Of these referrals, 33% (41) were for paediatric cases. Consulting specialists, who were based in five countries, were volunteers. Referring doctors were from 24 hospitals in 12 developing countries. The median time from referral to definitive reply was 1.5 days (interquartile range 0.6-4.9). There was an 85% response rate (n = 106) to a survey concerning the value of the consultation to the referring doctor. All the referring doctors who responded made positive comments about the service and half said that it improved their management of the case. The second-opinion consultation system operated by the Swinfen Charitable Trust represents an example of a global e-health system operated for altruistic, rather than commercial, reasons.