Challenges In Medical Management Research Articles

Typhoid Fever: The challenges of medical management

No Abstract. Keywords : Typhoid; medical management; challenges Annals of Ibadan Postgraduate Medicine Vol. 3 (1) 2005: pp. 60-68

SUSPECTED OVARIAN TUMOURS IN 16-ROW CT SCANNER ANGIOGRAFY-PRELIMINARY REPORT

Background General practitioners (GPs) manage the drug therapies of people with chronic diseases, and poor adherence to medication remains a major challenge. Objective This qualitative study examined GPs’ insights into non-adherence and ways of overcoming this problem. Methods We ran four focus groups comprising 16 GPs at the Kirkkonummi Health Centre (Southern Finland). Interviews were audiotaped, transcribed verbatim and analysed by inductive content analysis. Main results The two main themes in the discussions with the GPs were non-adherence in the care of chronic disease and increased need for medicine information. The medication management challenges identified were related to: patient-specific factors, the healthcare system, characteristics of drug therapies and the function and role of healthcare professionals as a team. To improve the situation, the GPs offered a number of solutions: improved coordination of care, better patient education and IT systems as well as enhanced interprofessional involvement in the follow-up of patients. Discussion and conclusions With an ageing population, the GPs were increasingly confronted with non-adherence in the care of chronic diseases. They had mostly a positive attitude towards organising care in a more interprofessional manner. To support medication adherence and self-management, the GPs appreciated pharmacists’ assistance especially with patients with polypharmacy and chronic diseases.

Medical management of the cardiac infant and child after surgical discharge.

Congenital heart disease (CHD) presents medical management challenges throughout the lifespan. As the complexity of the lesion increases, so do the management challenges. These issues include medication use; short-term postoperative management monitoring of growth, nutrition, development, family impact, immunization; and long-term management issues. The knowledge base in this field is ever growing, and only with knowing what to expect can we identify the unexpected and make that part of our understanding of the care of children with CHD.

Are Medicare Patients Sicker, More Complex, and at a Higher Risk for Perioperative Complications?

To the Editor: We are concerned about the recent decision of the Health Care Finance Administration (HCFA) to remove the physician involvement rule for anesthesia care for Medicare patients (1). Recently, Silber et al. (2) showed that the involvement of an anesthesiologist in medical direction was associated with a decreased incidence of complications and death in elderly (over 65 yr) Medicare recipients. This is consistent with our clinical impression that Medicare beneficiaries present more medically complex situations, thus making the task of providing safe perioperative management more difficult. Because medical complexity, as assessed by the ASA physical status classification system, correlates highly with perioperative morbidity and mortality (3,4), we tested our clinical impression by performing a one-year retrospective review of patients who were scheduled for ambulatory surgery or for admission on the morning of surgery and who were evaluated preoperatively by an anesthesiologist in the Department of Anesthesiology at the University of Texas Medical Branch between September 1, 1995, and August 31, 1996. Both payer class and ASA physical status were noted. We grouped together ASA physical status I and II patients (representing relatively healthy patients or patients with mild systemic disease) and ASA physical status III and IV patients (representing medically complex patients with severe or incapacitating systemic disease). We then compared Medicare patients with non-Medicare patients (those who had other or no insurance coverage) and their ASA physical status using χ2 analysis (P < 0.05 significant). We reviewed records of 6412 patients, 917 of whom were insured by Medicare and 5495 of whom were not. The percentage of each group in each ASA physical status is displayed in Table 1. Of the total number of Medicare patients represented, 50% had severe or incapacitating systemic disease compared with only 21% of non-Medicare patients. This difference was statistically significant (P < 0.001).Table 1: Payer and ASA Physical Status DistributionBecause ASA physical status is defined by the extent of systemic disease and correlates with anesthetic morbidity and mortality, our results confirm the clinical impression that Medicare patients are more medically complex and have a higher risk of perioperative morbidity than non-Medicare patients. Thus, the decision of HCFA to remove physician supervision as a minimum benefit to Medicare patients undergoing anesthesia is highly questionable, primarily because it removes the requirement for supervision for exactly those patients who are most likely to present complex medical management challenges. HCFA’s zeal to give hospitals greater flexibility in delivering care is not without consequences—their decision must be viewed with the understanding that the patients affected by this change in the minimum standard of care are sicker, medically more complex, and at higher risk for perioperative complications. Amr E. Abouleish MD, MBA Donald S. Prough MD

Are Medicare Patients Sicker, More Complex, and at a Higher Risk for Perioperative Complications?

To the Editor: We are concerned about the recent decision of the Health Care Finance Administration (HCFA) to remove the physician involvement rule for anesthesia care for Medicare patients (1). Recently, Silber et al. (2) showed that the involvement of an anesthesiologist in medical direction was associated with a decreased incidence of complications and death in elderly (over 65 yr) Medicare recipients. This is consistent with our clinical impression that Medicare beneficiaries present more medically complex situations, thus making the task of providing safe perioperative management more difficult. Because medical complexity, as assessed by the ASA physical status classification system, correlates highly with perioperative morbidity and mortality (3,4), we tested our clinical impression by performing a one-year retrospective review of patients who were scheduled for ambulatory surgery or for admission on the morning of surgery and who were evaluated preoperatively by an anesthesiologist in the Department of Anesthesiology at the University of Texas Medical Branch between September 1, 1995, and August 31, 1996. Both payer class and ASA physical status were noted. We grouped together ASA physical status I and II patients (representing relatively healthy patients or patients with mild systemic disease) and ASA physical status III and IV patients (representing medically complex patients with severe or incapacitating systemic disease). We then compared Medicare patients with non-Medicare patients (those who had other or no insurance coverage) and their ASA physical status using χ2 analysis (P < 0.05 significant). We reviewed records of 6412 patients, 917 of whom were insured by Medicare and 5495 of whom were not. The percentage of each group in each ASA physical status is displayed in Table 1. Of the total number of Medicare patients represented, 50% had severe or incapacitating systemic disease compared with only 21% of non-Medicare patients. This difference was statistically significant (P < 0.001).Table 1: Payer and ASA Physical Status DistributionBecause ASA physical status is defined by the extent of systemic disease and correlates with anesthetic morbidity and mortality, our results confirm the clinical impression that Medicare patients are more medically complex and have a higher risk of perioperative morbidity than non-Medicare patients. Thus, the decision of HCFA to remove physician supervision as a minimum benefit to Medicare patients undergoing anesthesia is highly questionable, primarily because it removes the requirement for supervision for exactly those patients who are most likely to present complex medical management challenges. HCFA’s zeal to give hospitals greater flexibility in delivering care is not without consequences—their decision must be viewed with the understanding that the patients affected by this change in the minimum standard of care are sicker, medically more complex, and at higher risk for perioperative complications. Amr E. Abouleish MD, MBA Donald S. Prough MD

P-2-19 - Multiple dose pharmacokinetics of sertraline in subjects with varying degrees of renal impairment

To initiate a call to action for ambulatory care pharmacists to play a more active role in transitional care management within primary care settings by discussing relevant opportunities, experiences, and challenges.With the shift to value-based health care, greater emphasis is being placed on improving patient care quality at the lowest cost. This represents an opportunity for pharmacist integration into primary care teams to address medication management challenges in the postdischarge period. Primary care pharmacists are uniquely positioned to close gaps in care not typically addressed by hospital-based programs. These pharmacists can provide complex transition interventions tailored toward individual patients, including comprehensive medication review, patient counseling, and direct collaboration with providers. For broad acceptance of these services, current challenges include identifying and prioritizing high-risk patients, establishing the cost-effectiveness of these strategies, and ultimately applying dissemination and implementation methodologies to increase the potential impact of these interventions.Opportunities are expanding for primary care pharmacists to play a more substantial role in transitional care management in sustainable ways. For widespread implementation of these strategies, additional research is necessary to determine their clinical effectiveness as well as cost-effectiveness and to understand better the barriers and facilitators to adopting these interventions.

Diffuse jejunoileitis of Crohn's disease.

Diffuse jejunoileitis is an uncommon, but important manifestation of Crohn's disease because of the associated high morbidity and challenges in medical management. Despite this there have been no studies of prognosis or management of diffuse jejunoileitis for nearly 20 years. This study analysed the outcome among 34 patients (20 women and 14 men) with diffuse jejunoileitis diagnosed between 1960 and 1991 including clinical features, medical and surgical management, death rates, current status, and prognosis. Diffuse jejunoileitis presents in younger patients (mean age at diagnosis 26.4 years) than those with distal ileal Crohn's disease (mean age at diagnosis 33.3 years). Nearly all presented with clear cut abdominal symptoms including a combination of colicky abdominal pain (91%), weight loss (62%), and diarrhoea (53%). Most patients had severe symptoms reflected by the fact that 77% had been treated with corticosteroids for periods of more than six months at some stage during their follow up. The mean follow up from diagnosis was 16 years. Twenty eight patients (82%) had at least one operation for diffuse jejunoileitis and two thirds of the patients (n = 21) required two or more operations. The frequency of surgical intervention was particularly high in the younger patients (r = 0.71, p < 0.001). The proportion of patients requiring surgery was highest in the first year after diagnosis. The annual operative rate was 15% for the first 10 years and then it fell to 5.2% in years 11-15, and 2.6% in years 16-20. The data suggest that the disease does burn itself out over time. The increasing use of strictureplasty for short strictures and the minimal use of resection has eliminated problems associated with the short small bowel syndrome. The longterm prognosis of this patients is good. Only two patients died (one of perforation of the jejunum and another of an unrelated bronchogenic carcinoma). After a mean interval from diagnosis of 16 year, 24 of 32 living patients are well and symptom free. Only eight have abdominal symptoms of whom three are receiving corticosteroid treatment and one azathioprine. The combination of anti-inflammatory drugs with the relief of recurrent obstructive symptoms by strictureplasty can together produce a good longterm prognosis in most patients with diffuse jejunoileitis.