Guideline-discordant care in acute myocardial infarction: predictors and outcomes

Objectives: To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care. Design: Retrospective cohort study. Setting: Two community general hospitals. Participants: 607 consecutive patients admitted with AMI between July 1997 and December 2000. Main outcome measures: Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay. Results: At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% Cl, 1.7-3.6), silent infarction (OR, 2.7; 95% Cl, 1.6-4.6), anterior infarction (OR, 2.5; 95% Cl, 1.7-3.8), a history of heart failure (OR, 6.3; 95% Cl, 3.7-10.7), chronic atrial fibrillation (OR, 3.2; 95% Cl, 1.5-6.4); and heart rate greater than or equal to 100 beats/min (OR, 2.1; 95% Cl, 1.4-3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% Cl, 1.22-4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% Cl, 0.90-7.1). Conclusions: Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI Such care appears to increase the risk of inhospital death.

Attitudes of paediatric medical ward staff to a dog visitation programme

No previous studies regarding either structured, strictly controlled pet visitation programmes in paediatric hospital wards or hospital staff attitudes towards them have been conducted in Australia. Information regarding these is essential in order to minimize problems during implementation of such programmes. The aim of the study was to analyse hospital staff perceptions regarding the introduction of a pet visitation programme in an acute paediatric medical ward prior to and following implementation of the programme and to compare attitudes between the various professional groups. The study consisted of two cross-sectional surveys. A total of 224 anonymous questionnaires were distributed to administrators, doctors, nursing staff and therapists 6 weeks before and 195 were distributed 12 weeks after the introduction of a pet visitation programme. Responses were received from 115 respondents (before the programme introduction) and 45 respondents (after the programme introduction). Prior to the introduction of the dog visitation programme, there were high staff expectations that the programme would distract children from their illness, relax children and that it was a worthwhile project for the hospital to undertake. Following implementation of the programme these expectations were strongly endorsed, in addition to the perception that the ward was a happier place, the work environment was more interesting and that nurses accepted the dogs. After implementation staff were less concerned about the possibility of dog bites and dogs doing damage to equipment. Allied health staff and non-clinical staff were more positive about the programme with respect to ward climate and acceptance than were doctors and nurses. We conclude that well-planned dog visitation programmes result in positive anticipation among staff and high levels of satisfaction following programme impact.

Outcome of stroke patients admitted to intensive care: Experience from an Australian teaching hospital

The objective of this study was to determine the mortality rate and the functional outcomes of stroke patients admitted to the intensive care unit (ICU) and to identify predictors of poor outcome in this population. The records of all patients admitted to the ICU with the diagnosis of stroke between January 1994 and December 1999 were reviewed. Patients with subarachnoid haemorrhage were excluded. Data were collected on clinical and biological variables, risk factors for stroke and the presence of comorbidities. Mortality (ICU, in-hospital and three-month) and functional outcome were used as end-points. In the six-year-period, 61 patients were admitted to the ICU with either haemorrhagic or ischaemic stroke. Medical records were available for only 58 patients. There were 23 ischaemic and 35 haemorrhagic strokes. The ICU, in-hospital and three-month mortality rates were 36%, 47% and 52% respectively. There were no significant differences in the prevalence of premorbid risk factors between survivors and non-survivors. The mean Barthel score was significantly different between the independent and dependent survivors (94 +/- 6 vs 45 +/- 26, P < 0.001). A substantial number of patients with good functional outcomes had lower Rankin scores (92% vs 11%, P < 0.001). Only 46% of those who were alive at three months were functionally independent. Intensive care admission was associated with a high mortality rate and a high likelihood of dependent lifestyle after hospital discharge. Haemorrhagic stroke, fixed dilated pupil(s) and GCS < 10 during assessment were associated with increased mortality and poor functional outcome.

How well do general practitioners deliver palliative care? A systematic review

General practitioners (GPs) deliver the majority of palliative care to patients in the last year of life. This article seeks to examine the nature of GP care, perceptions of the GPs themselves and others of that care, the adequacy of palliative care training, issues relating to accessibility of GPs to palliative care patients, and strategies that may be of use in encouraging more effective delivery of palliative care by GPs. Medline and PubMed databases from 1966 to 2000 were searched, and 135 references identified. Sixty-six of these described studies relevant to GP palliative care. GPs value this part of their work. Most of the time, patients appreciate the contribution the GP makes to palliative care particularly if the GP is accessible, takes time to listen, allows patient and carer to ventilate their feelings, and is seen to be making efforts made regarding symptom relief. However, reports from bereaved relatives suggest that palliative care is performed less well in the community than in other settings. GPs express discomfort about their competence to perform palliative care adequately. They tend to miss symptoms which are not treatable by them, or which are less common. However, with appropriate specialist support and facilities, GPs have been shown to deliver sound and effective care. GP comfort working with specialist teams increases with exposure to this form of patient management, as does the understanding of the potential other team members have in contributing to the care of the patient. Formal arrangements engaging GPs to work with specialist teams have been shown to improve functional outcomes, patient satisfaction, improve effective use of resources and improve effective physician behaviour in other areas of medicine. Efforts by specialist services to develop formal involvement of GPs in the care of individual patients, may be an effective method of improving GP palliative care skills and appreciation of the roles specialist services can play.

Does primary medical practitioner involvement with a specialist team improve patient outcomes? A systematic review.

Patients with chronic or complex medical or psychiatric conditions are treated by many practitioners, including general practitioners (GPs). Formal liaison between primary and specialist is often assumed to offer benefits to patients The aim of this study was to assess the efficacy of formal liaison of GPs with specialist service providers on patient health outcomes, by conducting a systematic review of the published literature in MEDLINE, EMBASE, PsychINFO, CINAHL and Cochrane Library databases using the following search terms family physicians': synonyms of 'patient care planning', 'patient discharge' and 'patient care team'; and synonyms of 'randomised controlled trials'. Seven studies were identified, involving 963 subjects and 899 controls. most health outcomes were unchanged, although some physical and functional health outcomes were improved by formal liaison between GPs and specialist services, particularly among chronic mental illness patients. Some health outcomes worsened during the intervention. Patient retention rates within treatment programmes improved with GP involvement, as did patient satisfaction. Doctor (GP and specialist) behaviour changed, with reports of more rational use of resources and diagnostic tests, improved clinical skills, more frequent use of appropriate treatment strategies, and more frequent clinical behaviours designed to detect disease complications Cost effectiveness could not be determined. In conclusion, formal liaison between GPs and specialist services leaves most physical health outcomes unchanged, but improves functional outcomes in chronically mentally ill patients. It may confer modest long-term health benefits through improvements in patient concordance with treatment programmes and more effective clinical practice.

Prospective independent validation of APACHE III models in an Australian tertiary adult intensive care unit

Evaluation of the performance of the APACHE III (Acute Physiology and Chronic Health Evaluation) ICU (intensive care unit) and hospital mortality models at the Princess Alexandra Hospital, Brisbane is reported. Prospective collection of demographic, diagnostic, physiological, laboratory, admission and discharge data of 5681 consecutive eligible admissions (1 January 1995 to 1 January 2000) was conducted at the Princess Alexandra Hospital, a metropolitan Australian tertiary referral medical/surgical adult ICU. ROC (receiver operating characteristic) curve areas for the APACHE III ICU mortality and hospital mortality models demonstrated excellent discrimination. Observed ICU mortality (9.1%) was significantly overestimated by the APACHE III model adjusted for hospital characteristics (10.1%), but did not significantly differ from the prediction of the generic APACHE III model (8.6%). In contrast, observed hospital mortality (14.8%) agreed well with the prediction of the APACHE III model adjusted for hospital characteristics (14.6%), but was significantly underestimated by the unadjusted APACHE III model (13.2%). Calibration curves and goodness-of-fit analysis using Hosmer-Lemeshow statistics, demonstrated that calibration was good with the unadjusted APACHE III ICU mortality model, and the APACHE III hospital mortality model adjusted for hospital characteristics. Post hoc analysis revealed a declining annual SMR (standardized mortality rate) during the study period. This trend was present in each of the non-surgical, emergency and elective surgical diagnostic groups, and the change was temporally related to increased specialist staffing levels. This study demonstrates that the APACHE III model performs well on independent assessment in an Australian hospital. Changes observed in annual SMR using such a validated model support an hypothesis of improved survival outcomes 1995-1999.

Effect of functional gain on satisfaction with medical rehabilitation after stroke

Objective: To examine the association between gain in motor and cognitive functional status with patient satisfaction 3-6 mo after rehabilitation discharge. Design: Patient satisfaction and changes in functional status were examined in 18,375 patients with stroke who received inpatient medical rehabilitation. Information was obtained from 144 hospitals and rehabilitation facilities contributing records to the Uniform Data System for Medical Rehabilitation and the National Follow-up Services. Results: Data analysis revealed significant (P < 0.05) differences in satisfaction responses based on whether information was collected from patient self-report or from a family member proxy, and the two subsets were analyzed separately. Logistic regression revealed the following significant predictors of satisfaction for data collected from stroke patients: cognitive and motor gain, rehospitalization, who the patient was living with at follow-up, age, and follow-up therapy. In the patient-reported data subset, compared with patients who showed improved cognitive or motor functional status, those with no change, respectively, had a 31% and 33% reduced risk of dissatisfaction. In addition, rehospitalized patients had a higher risk of dissatisfaction. For the proxy reported data subset, significant influences on satisfaction were health maintenance, rehospitalization, stroke type, ethnicity, cognitive FIM(TM) gain, length of stay, and follow-up therapy. Conclusions: Ratings of satisfaction with rehabilitation services were affected by change in functional status and whether the information was collected from patient rating or proxy response.

An e-marketplace of healthcare and social care services: the perceived interest

Purpose – The health and social care sector is receiving growing attention due to the increased life expectancy and to the public demand for a better quality of life and better health services. New cost-efficient approaches are required, and the paper aims to present and discuss the main results of a study undertaken in a Portuguese municipality on the perceived relevance of an e-marketplace of social and healthcare services for the inhabitants in general, and for people with special needs in particular, and the identification of the most relevant services to be offered through this platform. Design/methodology/approach – A wide survey was undertaken to identify the needs of potential users and their expectancies with relation to the proposed platform. The results of the study are a support for the project promoters to understand the viability of the solution and the requirements to the deployment of the pilot experiment, as well as to drive the selection of domains of activities/classes of services to be offered by the platform. Findings – Services such as information about healthcare services, home monitoring/accompanying services 24 hours per day, and personal hygiene services provided at home are the ones recognized by the inquired citizens as the most important, which indicates that the potential users will be mostly people with special needs or their family or caregivers. Originality/value – While still at a preliminary development phase, the project represents a good opportunity to develop a totally innovative service with high potential impact for the senior population and for individuals with special needs.

Notes on health care planning in Latin America and the Caribbean

Attention is called to the fact that the efforts to improve health of populations in Latin America have generally failed. The inequality in the distribution of ill-health is great. The authors accept the fact that the lack of resources available to the health sector may be a restriction towards the improvement of the situation, but they argue that a much more important issue is the misuse of such resources and their maldistribution within the health sector. The lack of integration and coordination between the health services, the conflict of public and private health systems, the under-utilization of existing services and the gap between planning and real implementation are discussed.

Metodological issues in measuring the detection of emotional disorders by primary care physicians: a review of the literature

A series of studies in the field of Epidemiological Psychiatry have been performed over the last two decades, and these have focused on the ability of primary care physicians to detect emotional disorders in the patients that attend their practices. The scientific methodology utilized in these studies is the subject of this review, which contains a discussion concerning: a) interviewer awareness bias; b) accuracy of the instruments and c) medical and psychological concepts involved in defining minor emotional disorders. Suggestions for change in the methodology are made in each of the sections of the review.

VirtualECare: group support in collaborative networks organizations for digital homecare

Collaborative Work plays an important role in today’s organizations, especially in areas where decisions must be made. However, any decision that involves a collective or group of decision makers is, by itself complex, but is becoming recurrent in recent years. In this work we present the VirtualECare project, an intelligent multi-agent system able to monitor, interact and serve its customers, which are, normally, in need of care services. In last year’s there has been a substantially increase on the number of people needed of intensive care, especially among the elderly, a phenomenon that is related to population ageing. However, this is becoming not exclusive of the elderly, as diseases like obesity, diabetes and blood pressure have been increasing among young adults. This is a new reality that needs to be dealt by the health sector, particularly by the public one. Given this scenarios, the importance of finding new and cost effective ways for health care delivery are of particular importance, especially when we believe they should not to be removed from their natural “habitat”. Following this line of thinking, the VirtualECare project will be presented, like similar ones that preceded it. Recently we have also assisted to a growing interest in combining the advances in information society - computing, telecommunications and presentation – in order to create Group Decision Support Systems (GDSS). Indeed, the new economy, along with increased competition in today’s complex business environments, takes the companies to seek complementarities in order to increase competitiveness and reduce risks. Under these scenarios, planning takes a major role in a company life. However, effective planning depends on the generation and analysis of ideas (innovative or not) and, as a result, the idea generation and management processes are crucial. Our objective is to apply the above presented GDSS to a new area. We believe that the use of GDSS in the healthcare arena will allow professionals to achieve better results in the analysis of one’s Electronically Clinical Profile (ECP). This achievement is vital, regarding the explosion of knowledge and skills, together with the need to use limited resources and get better results.

A checklist for patient safety rounds at the care pathway level

Objective - To define a checklist that can be used to assess the performance of a department and evaluate the implementation of quality management (QM) activities across departments or pathways in acute care hospitals. Design - We developed and tested a checklist for the assessment of QM activities at department level in a cross-sectional study using on-site visits by trained external auditors. Setting and Participants - A sample of 292 hospital departments of 74 acute care hospitals across seven European countries. In every hospital, four departments for the conditions: acute myocardial infarction (AMI), stroke, hip fracture and deliveries participated. Main outcome measures - Four measures of QM activities were evaluated at care pathway level focusing on specialized expertise and responsibility (SER), evidence-based organization of pathways (EBOP), patient safety strategies and clinical review (CR). Results - Participating departments attained mean values on the various scales between 1.2 and 3.7. The theoretical range was 0-4. Three of the four QM measures are identical for the four conditions, whereas one scale (EBOP) has condition-specific items. Correlations showed that every factor was related, but also distinct, and added to the overall picture of QM at pathway level. Conclusion - The newly developed checklist can be used across various types of departments and pathways in acute care hospitals like AMI, deliveries, stroke and hip fracture. The anticipated users of the checklist are internal (e.g. peers within the hospital and hospital executive board) and external auditors (e.g. healthcare inspectorate, professional or patient organizations).