Resource utilisation, length of hospital stay, and pattern of investigation during acute medical hospital admission

To describe the patient demographic characteristics and organisational factors that influence length of stay (LOS) among emergency medical admissions. Also, to describe differences in investigation practice among consultant physicians and to examine the impact of these on LOS.

From hyperactive children to ADHD adults:Observations on the expansion of medical categories

Medicalization is by definition, about the extension of medical boundaries. Analogous to "domain expansion," extant medicalized categories can expand to become broader and more inclusive. This paper examines the emergence of Attention Deficit Hyperactivity Disorder (ADHD) in adults. ADHD, commonly known as Hyperactivity, became established in the 1970s as a diagnosis for children; it expanded first to include "adult hyperactives" and, in the 1990s, "ADHD Adults." This allowed for the inclusion of an entire population of people and their problems that were excluded by the original conception of hyperactive children. We show how lay, professional, and media claims help establish the expanded diagnostic category. We identify particular aspects of the social context that contributed to the rise of adult ADHD and outline some of the social implications of ADHD in adults, especially the medicalization of underperformance and the availability of new disability rights. Adult ADHD serves as an exemplar of several cases of diagnostic expansion, an important avenue of increasing medicalization.

Canaries Coalmines Thunderstones 2010:"Suppressing the Medical Model”; “Family at War”; and “The Fallenness of Humanity"

A Poetic Annual

Identifying research priorities in long term care homes

Concerns about the quality of care in long term care (LTC) homes range from inadequate daily care to understaffing and insufficient funding. LTC decision makers are challenged to keep up with the changing demographics of residents admitted to LTC who have increasingly complex care needs. Decisions regarding LTC policies and procedures need to be informed by research that identifies the most effective and efficient care practices.This study solicited feedback from LTC decision makers in Ontario, Canada, regarding research priorities to guide improvement in the quality of care in LTC homes. Representatives from 134 LTC homes responded (53.6% response rate). Nine thematic areas of research were identified: delivery of care; staffing; organization and structure of homes; funding; indicators, standards, policies, and procedures; managing difficult behaviors; education; safety; and infectious disease control. It is anticipated that these themes will steer research down a path that is responsive to the information needs of practitioners in LTC homes. © 2012 American Medical Directors Association, Inc.

A qualitative study of the relationship between clinician attributes, organization, and patient characteristics on implementation of a disease management program

The purpose of this study was to examine the challenges of integrating an asthma disease management (DM) program into a primary care setting from the perspective of primary care practitioners. A second goal was to examine whether barriers differed between urban-based and nonurban-based practices. Using a qualitative design, data were gathered using focus groups in primary care pediatric practices. A purposeful sample included an equal number of urban and nonurban practices. Participants represented all levels in the practice setting. Important themes that emerged from the data were coded and categorized. A total of 151 individuals, including physicians, advanced practice clinicians, registered nurses, other medical staff, and nonmedical staff participated in 16 focus groups that included 8 urban and 8 nonurban practices. Content analyses identified 4 primary factors influencing the implementation of a DM program in a primary care setting. They were related to providers, the organization, patients, and characteristics of the DM program. This study illustrates the complexity of the primary care environment and the challenge of changing practice in these settings. The results of this study identified areas in a primary care setting that influence the adoption of a DM program. These findings can assist in identifying effective strategies to change clinical behavior in primary care practices. © 2008 Mary Ann Liebert, Inc.

Understanding the collaborative experience between researchers and health care practitioners:Implications for gerontological nursing practice

The health care field is a new arena for collaborative research carried out by practitioner-researcher teams. Although the current literature discusses factors supportive of such teams, most evidence is anecdotal or descriptive of pilot projects. In this article, the authors use survey and interview data to document health care practitioners' views on collaborative research with an experienced researcher/ mentor. Topics covered include a description of the research project and process, positive and negative aspects of doing research, expectations, recommendations to colleagues starting research, and desirable characteristics in practitioners and researchers on collaborative research teams. Of all attributes mentioned, personal traits and skills were among the most frequently mentioned for both practitioners and researchers, followed by research knowledge and attitudes for practitioners, and teaching skills for researchers. The article also addresses factors important to the success of collaborative research: how to develop a project, characteristics of collaborative team members, team functioning, and institutional support. Copyright © 2000 Taylor & Francis.

Agreement between self-report and medical records on signs and symptoms of respiratory illness

Background: Information on patient symptoms can be obtained by patient self-report or medical records review. Both methods have limitations. Aims: To assess the agreement between self-report and documentation in the medical records of signs/symptoms of respiratory illness (fever, cough, runny nose, sore throat, headache, sinus problems, muscle aches, fatigue, earache, and chills). Methods: Respondents were 176 research participants in the Hutterite Influenza Prevention Study during the 2008-2009 influenza season with information about the presence or absence of signs/symptoms from both self-report and primary care medical records. Results: Compared with medical records, lower proportions of self-reported fever, sore throat, earache, cough, and sinus problems were found. Total agreements between self-report and medical report of symptoms ranged from 61% (for sore throat) to 88% (for muscle aches and earache), with kappa estimates varying from 0.05 (for chills) to 0.41 (for cough) and 0.51 (for earache). Negative agreement was considerably higher (from 68% for sore throat to 93% for muscle aches and earache) than positive agreement (from 13% for chills to 58% for earache) for each symptom except cough where positive agreement (77%) was higher than negative agreement (64%). Agreements varied by age group. We found better agreement for earache (kappa=0.62) and lower agreements for headache, sinus problems, muscle aches, fatigue, and chills in older children (aged =5 years) and adults. Conclusions: Agreements were variable depending on the specific symptom. Contrary to research in other patient populations which suggests that clinicians report fewer symptoms than patients, we found that the medical record captured more symptoms than selfreport. Symptom agreement and disagreement may be affected by the perspectives of the person experiencing them, the observer, the symptoms themselves, measurement error, the setting in which the symptoms were observed and recorded, and the broader community and cultural context of patients. © 2012 Primary Care Respiratory Society UK. All rights reserved.

Access to medical records for research purposes:Varying perceptions across research ethics boards

Introduction: Variation across research ethics boards (REBs) in conditions placed on access to medical records for research purposes raises concerns around negative impacts on research quality and on human subject protection, including privacy. Aim: To study variation in REB consent requirements for retrospective chart review and who may have access to the medical record for data abstraction. Methods: Thirty 90-min face-to-face interviews were conducted with REB chairs and administrators affiliated with faculties of medicine in Canadian universities, using structured questions around a case study with open-ended responses. Interviews were recorded, transcribed and coded manually. Results: Fourteen sites (47%) required individual patient consent for the study to proceed as proposed. Three (10%) indicated that their response would depend on how potentially identifying variables would be managed. Eleven sites (38%) did not require consent. Two (7%) suggested a notification and opt-out process. Most stated that consent would be required if identifiable information was being abstracted from the record. Among those not requiring consent, there was substantial variation in recognising that the abstracted information could potentially indirectly re-identify individuals. Concern over access to medical records by an outside individual was also associated with requirement for consent. Eighteen sites (60%) required full committee review. Sixteen (53%) allowed an external research assistant to abstract information from the health record. Conclusions: Large variation was found across sites in the requirement for consent for research involving access to medical records. REBs need training in best practices for protecting privacy and confidentiality in health research. A forum for REB chairs to confidentially share concerns and decisions about specific studies could also reduce variation in decisions.

Medical versus surgical interventions for open angle glaucoma.

BACKGROUND: Open angle glaucoma (OAG) is a common cause of blindness.

OBJECTIVES: To assess the effects of medication compared with initial surgery in adults with OAG.

SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2012), EMBASE (January 1980 to August 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to August 2012), Biosciences Information Service (BIOSIS) (January 1969 to August 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to August 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), Zetoc, the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 1 August 2012. The National Research Register (NRR) was last searched in 2007 after which the database was archived. We also checked the reference lists of articles and contacted researchers in the field.

SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing medications with surgery in adults with OAG.

DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We contacted study authors for missing information.

MAIN RESULTS: Four trials involving 888 participants with previously untreated OAG were included. Surgery was Scheie's procedure in one trial and trabeculectomy in three trials. In three trials, primary medication was usually pilocarpine, in one trial it was a beta-blocker.The most recent trial included participants with on average mild OAG. At five years, the risk of progressive visual field loss, based on a three unit change of a composite visual field score, was not significantly different according to initial medication or initial trabeculectomy (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.54 to 1.01). In an analysis based on mean difference (MD) as a single index of visual field loss, the between treatment group difference in MD was -0.20 decibel (dB) (95% CI -1.31 to 0.91). For a subgroup with more severe glaucoma (MD -10 dB), findings from an exploratory analysis suggest that initial trabeculectomy was associated with marginally less visual field loss at five years than initial medication, (mean difference 0.74 dB (95% CI -0.00 to 1.48). Initial trabeculectomy was associated with lower average intraocular pressure (IOP) (mean difference 2.20 mmHg (95% CI 1.63 to 2.77) but more eye symptoms than medication (P = 0.0053). Beyond five years, visual acuity did not differ according to initial treatment (OR 1.48, 95% CI 0.58 to 3.81).From three trials in more severe OAG, there is some evidence that medication was associated with more progressive visual field loss and 3 to 8 mmHg less IOP lowering than surgery. In the longer-term (two trials) the risk of failure of the randomised treatment was greater with medication than trabeculectomy (OR 3.90, 95% CI 1.60 to 9.53; hazard ratio (HR) 7.27, 95% CI 2.23 to 25.71). Medications and surgery have evolved since these trials were undertaken.In three trials the risk of developing cataract was higher with trabeculectomy (OR 2.69, 95% CI 1.64 to 4.42). Evidence from one trial suggests that, beyond five years, the risk of needing cataract surgery did not differ according to initial treatment policy (OR 0.63, 95% CI 0.15 to 2.62).Methodological weaknesses were identified in all the trials.

AUTHORS' CONCLUSIONS: Primary surgery lowers IOP more than primary medication but is associated with more eye discomfort. One trial suggests that visual field restriction at five years is not significantly different whether initial treatment is medication or trabeculectomy. There is some evidence from two small trials in more severe OAG, that initial medication (pilocarpine, now rarely used as first line medication) is associated with more glaucoma progression than surgery. Beyond five years, there is no evidence of a difference in the need for cataract surgery according to initial treatment.The clinical and cost-effectiveness of contemporary medication (prostaglandin analogues, alpha2-agonists and topical carbonic anhydrase inhibitors) compared with primary surgery is not known.Further RCTs of current medical treatments compared with surgery are required, particularly for people with severe glaucoma and in black ethnic groups. Outcomes should include those reported by patients. Economic evaluations are required to inform treatment policy.