Secondary Care Sectors Research Articles

Poor outcome in patients with spine‐related leg or arm pain who are involved in compensation claims: a prospective study of patients in the secondary care sector

Objective: To investigate whether poor outcome after spinal pain episodes is linked with the claim process and, if so, whether this link is independent of other potential risk factors of chronic pain and disability in patients with spine‐related leg or arm pain.Methods: A 1‐year prospective outcome study with internal control groups in two Danish secondary care, public, multidisciplinary, non‐surgical spine clinics. Patients with low back pain (LBP) radiating to the leg (n = 1243) or with neck and arm pain thought to emanate from the neck (n = 202) were referred to the clinics by their general practitioners. Rheumatologists, physiotherapists, and nurses examined, treated, and informed the patients based on cognitive principles. Follow‐up data were collected with a postal questionnaire. Claim, defined as seeking some sort of financial compensation or filing any sort of financial claim, such as workers' compensation, was the main independent variable. Potential confounders examined were: age, sex, social class, smoking, duration and severity of pain and disability. The main outcome measures were: global assessment (main outcome variable), pain, disability, and intake of analgesics.Results: Financial claims were registered by 31% of patients. After adjustment for covariates, the odds ratio for claim and no improvement was calculated to be 4.2 (95% CI 2.8–6.2) for the LBP/leg patients and 17.4 (95% CI 5.1–60.1) for the neck/arm patients.Conclusion: A claim for financial compensation is strongly and independently linked with a poor prognosis for Danish patients with pain radiating from the low‐back or neck.

Preventive home visits to older people in Denmark

In Denmark, political decisions improved the implementation of 'preventative thinking' into every-day clinical work. The potential benefits of preventive efforts have been supported by legislative and administrative incentives, and an ongoing effort to remain focused on the benefits of these initiatives towards older people is politically formulated and underlined as part of the new structured municipality reform. Evidence of beneficial effects of health promotion and prevention of disease in old age is well documented. In-home visits with individualised assessments make it possible to reach older persons not normally seen in the health care system. In-home assessment is not just a health check, but also an opportunity to meet individual needs that may be of importance for older people to stay independent. Preventive home visits may be part of an overall culture and strategy to avoid or prevent functional decline. There is an urgent need of an interdisciplinary teamwork and management for such programmes, incorporating flexible cooperation between the primary and secondary health care sector. The value and importance of geriatric and gerontological education is evidence based.

Challenges for IT-supported shared care: a qualitative analyses of two shared care initiatives for diabetes treatment in Denmark

To investigate the circumstances as to why it is so difficult in the primary care sector to implement IT based infrastructures supporting shared care. The qualitative analysis includes two separate case studies of IT-supported shared care implemented in two different regions of Denmark throughout 2005. The study comprises 21 interviews and 35 hours of observations. The data were analysed through a coding process that led to the emergence of three main challenges impeding the organisational implementation of IT-supported shared care. The two cases faced the same challenges that led to the same problem: The secondary care sector quickly adopted the system while the primary sector was far more sceptical towards using it. In both cases, we observe a discrepancy of needs satisfied, especially with regard to the primary care sector and its general practitioners which hinder bridging the primary sector (general practitioners) and the secondary sector (hospitals and outpatient clinics). Especially the needs associated with the primary sector were not being satisfied. We discovered three main challenges related to bridging the gap between the two sectors: (1) Poor integration with the general practitioners' existing IT systems; (2) low compatibility with general practitioners' work ethic; (3) and discrepancy between the number of diabetes patients and the related need for shared care. We conclude that development of IT-supported shared care must recognise the underlying and significant differences between the primary and secondary care sectors: If IT-supported shared care does not meet the needs of the general practitioners as well as the needs of the secondary care sector the initiative will fail.

Changing GPs' prescription patterns through guidelines and feedback. Intervention study

To investigate whether and how a multi-dimensional intervention including clinical guidelines on the choice of medical treatment in the primary and the secondary health care sector, and individual feedback to general practices about their own and other practices' prescription patterns in five Anatomical Therapeutic Chemical classification system (ATC)-groups was followed by changes in the practices' prescription pattern. Prospective historical registry study and a questionnaire study of GPs' self-reported use of guidelines and feedback. In every ATC-group the number of prescribed defined daily doses (DDDs) kept growing after the intervention, while potential savings by DDD decreased. Individual practices' changes in the prescription pattern differed by ATC-group and practices with high potential savings/DDD before the intervention showed the greatest relative reduction in potential savings/DDD. The county's average cost/DDD for the five ATC-groups declined from above the Danish average before the intervention to a level below the average cost/DDD after the intervention. In the questionnaire study (response rate: 79%), 69% of respondents had read the guidelines and 78% reported that the feedback influenced their prescription of drugs. The observed changes in drug costs and potential savings were not due to volume effects but a combination of price effects, including generic substitution and choice of less expensive analogues, demonstrating that it is possible to change GPs' prescription patterns without interfering with patients' access to treatment or with GPs' clinical freedom.'

Chronological Analysis of Disparities in Numbers of Ordinary Hospital Beds and X-Ray Computed Tomography Scanners among Secondary Medical Care Sectors

In this study, we aimed at examining how disparities in selected medical care resources across secondary medical care sectors (SMCSs) changed over a twelve-year period following the introduction of the Medical Care Plan. Changes in all SMCS boundaries prior to 2002 were identified from data published by the Ministry of Health and Welfare and prefectural governments. The per capita numbers of ordinary hospital beds and X-ray computed tomography (CT) scanners in hospitals were chosen as indicators of medical care resources, representing respectively mandatory and nonmandatory components of the Medical Care Plan. Their interquartile range and quartile variation coefficient were used as measures of disparity among SMCSs. The number of ordinary hospital beds per capita did not increase significantly between 1988 and 2000 in Group-A SMCSs (population density > or = 1000/km2) but increased significantly in Group-R (population density < 300/km2) and Group-U (300/km2 < or = population density < 1000/km2) SMCSs. The disparity in the per capita numbers of hospital beds among all SMCSs however decreased as a whole. The per capita numbers of X-ray CT scanners increased significantly in all three groups of SMCSs between 1987 and 1999. The coefficient of quartile variation for X-ray CT scanners remained larger than that for ordinary hospital beds over the 12-year period with the exception of Group-A SMCSs. The disparities in medical care resources among SMCSs decreased for ordinary hospital beds more markedly than for X-ray CT scanners, possibly as an effect of the implementation of the Medical Care Plan.

Development of the specialist menopause pharmacist (SMP) role within a research framework

To determine the potential contribution of a new healthcare practice model, the specialist menopause pharmacist (SMP) role. Post pilot, the SMP's remit was proposed as combining clinical practice (service delivery) and research studies, with emphasis on strengthening liaison between the secondary and primary care sectors. Action research, a qualitative research technique, was selected to document role development in the first year. Here the pharmacist-researcher's focus was a local situation where the effects of a particular change, involving people who were part of the situation, were assessed. The change factor was the introduction of the pharmacist to the multi-disciplinary specialist team. The pharmacist-researcher did not attempt to hold anything constant but observed the changes occurring in a systematic manner. Analysis of on-going collaborative professional activity generated the hypothesis that the role was of use in enhancing patient care. Using triangulation and focusing on the descriptive phrase 'of use', it was then possible to study SMP implemented 'actions' that would be accepted as being 'useful' SMP functions. The aim was to test for reliability and obtain data with greater range and accuracy. The three studies undertaken included a controlled, questionnaire study asking for patients' views on the pharmacist service, auditing health professionals usage of the pharmacist operated telephone help-line, and assessing the impact of structured on-site training on community pharmacists. Overall impact and achievements over 3 years, against a background where the SMP role continued to develop during the study. Action research methodology engendered reflective practice, enabling the SMP to be both the service delivery provider (the intervention) and the researcher. This pharmacist practice model is accepted both by patients and health professional colleagues. The remit combines clinical practice with on-going research studies. In the UK setting, the SMP can undertake numerous liaison activities between secondary and primary care sectors to facilitate enhanced delivery of menopause patient care. Using an action research approach, and combining qualitative and quantitative methods to complement data collection, it was possible to assess the specialist pharmacist role in depth.

Supporting parents in managing drugs for children with cystic fibrosis

A semi-structured interview guide was used to interview 17 parents of children with cystic fibrosis identified through a shared care patient database at a London hospital to examine parents' medication-related roles and problems. Parents described their responsibilities in the home and the problems experienced, including adherence to regiments, involvement in decision-making, and relationships with the hospital teams and other healthcare professionals. The findings confirmed medication management as an integral part of the informal caring role. Many practical problems of ensuring the availability and administration of medication on a regular basis were described. Information gaps and problems with medication adherence increased the stress of providing effective care. The involvement of healthcare professionals across primary, secondary and tertiary care sectors in supporting parents in all aspects of medication management, including the development of strategies for transferring the responsibility for medication to their children, must be improved.

On the Quality Variation of Primary Health Care Services: A Test of the ‘Inverse Care Law’ for General Practice

Tudor Hart's 1971 study, based in Wales, was the first to hypothesise the existence of an inverse relationship which often prevails between those communities with the most pressing health needs and the lack or poor quality of health services provided locally. Over the last thirty years there have been many demonstrations of the validity of Hart's ‘inverse care law’ in relation to the provision of, and access to, particular services in the primary and secondary health care sectors. In this paper we provide a direct test of the relationship between an aggregate measure of quality of general practitioner (GP) services and a measure of health need of local populations. We examine the variation in quality of GP services, derived from eligibility for sustained quality payments, over the 131 practices of the former Bro Taf Health Authority in South Wales. Using logit regression analysis we have explored the extent to which the local deprivation of practice populations and the size of practice account for the variation in the quality of provision within the authority. The analysis supports the conclusion that the ‘inverse care law’ is a strong feature of provision. Both the eligibility of GP practices for quality payments and the availability of training practices are significantly higher in the least deprived wards than those in the most deprived ones.

Health care utilisation among individuals reporting long-term pain: an epidemiological study based on Danish National Health Surveys

Individuals reporting long-term pain in the 1994 and 2000 Danish Health and Morbidity Surveys, which included random samples of 6000 and 16,684 persons respectively, were investigated concerning their use of the health care systems. A considerably higher use was observed in the pain population in the primary as well as the secondary health care sector, compared with a no pain control group. In 1994, individuals reporting long-term pain had on average 12.8 contacts per year to the primary health care sector compared with 7.3 for the control group. Use of secondary health care sector as estimated by hospital admission frequency and number of in-hospital days was not only significantly higher for the pain group but showed also an increasing tendency during the periods investigated (1991–1997). Women used the health care system significantly more than men, whereas age did not seem to influence. In conclusion, individuals reporting long-term/chronic pain have a significantly higher use of the health care system than individuals without long-term/chronic pain complaints. Reasons may be ascribed to within-patient factors, factors within the health care system (insufficient knowledge on chronic pain resulting in the seeking after a somatic diagnosis, and difficulties in recognizing the endpoint of reasonable treatment attempts), and societal factors (legislation on disability and compensation).

Predictors of falls in a high risk population: results from the prevention of falls in the elderly trial (PROFET)

Objectives: The prevention of falls in the elderly trial (PROFET) provides evidence of the benefits of structured interdisciplinary assessment of older people presenting to the accident and emergency department with...

Realising ‘Joined-Up’ Geography in the National Health Service: The Role of Geographical Information Systems?

This paper focuses on the use of geographical information systems (GIS) within primary and secondary health care sectors in the United Kingdom in relation to wider notions of ‘joined-up’ government—a key tenet of central government initiatives aimed at addressing problems such as social exclusion and polarisation. Drawing on findings from a national-level questionnaire survey, and follow-up semi-structured interviews with key respondents from the National Health Service (NHS), we have found that there has been an increase in GIS uptake within health organisations in the last decade. However, there has been limited collaboration between NHS organisations and local authorities on projects that utilise GIS. This lack of interorganisational activity is underpinned by the lack of a service-level agreement for digital data provision within NHS organisations, ambiguous understandings of data confidentiality requirements, and a limited awareness of the benefits of joined-up working arrangements. The paper concludes with a suggestion that significant organisational and cultural changes are required to facilitate enabling contexts for enhanced collaborative use of GIS between NHS organisations and local authorities, in order to support the wider joined-up government agenda currently being promoted in the United Kingdom.

This issue of JAN

This issue of JAN

Where are the weakest links?: a descriptive study of discrepancies in prescribing between primary and secondary sectors of mental health service provision

AIMS AND METHODTo investigate the transfer of information regarding prescribed medication between primary and secondary care sectors. Patients aged 18–65 years, ready for discharge from hospital, were invited to participate. Prescribed medication was recorded from their hospital and general practitioner records. The significance of discrepancies identified between medication lists was assessed independently by four judges.RESULTSDiscrepancies occurred for 39 out of 43 patients at each stage of medication information transfer. Discrepancies at the time of admission and following discharge occurred in 69% and 43%, respectively, of drugs studied. It was judged that harm would occur to the patient, should the discrepancy be reproduced, in 24% and 18%, respectively, of cases.CLINICALIMPLICATIONS Discrepancies in the transfer of information regarding prescribed medication may result in harm to patients.

Construction of a GP integration model

There are frequent calls to improve integration of health services, within and between primary and secondary care sectors. In Australia, general medical practitioners (GPs) are central to these endeavours. This paper aims to better conceptualise GP integration and to develop a model and index based on this. A conceptualisation of integration is proposed based on integration fundamentally as an activity or process not structure. Integration process is the frequency and quality of episodes of information exchange involving the GP and another practitioner or patient and aimed at fulfilling the objectives of the health care system with regard to patient care. These are both direct responses to structural forces and emergent GP capacities and dispositions. The content of this typology was studied using Concept Mapping in 11 groups of GPs, consumers and other practitioners. Clusters of related statements within thematic domains were used as the basis for a provisional model. This was tested using confirmatory factor analysis in a data set derived from a national probability sample of 501 GPs. Some re-specification of the model was necessary, with three integration process factors needing to be subdivided. One factor congeneric model assumptions were used to identify the constituent items for these factors. The result was a model in which 50 items measured nine integration process factors and 20 items measured five enabling factors. Two distinct but correlated higher order factors, relating to individual patient care and public (or community) health—in contrast to a single higher order factor for integration—were identified. The re-specified model was tested with a new sample of 151 GPs and exhibited strong psychometric properties. Reliability and validity were acceptable to this stage of the indices’ development. Further testing of the index is necessary to demonstrate factor invariance of the indices in other contexts as well as their utility in cross-structural analysis. That said, the indices have immediate uses.

Commentary: Audit of mortality in type 2 diabetes

The paper by Allan et al underscores (a) the view that diabetes is a cardiovascular disease and (b) the appropriateness of the management of patients with type 2 diabetes in primary care. Diabetes is the ideal candidate for shared care between the primary and secondary care sectors. In a UK survey carried out in 1991, diabetes care schemes accounted for 48% of all shared care schemes in operation. The practical design varied widely, and about one third had been set up only since 1989. Shared care has been defined as “the joint participation of hospital consultants and general practitioners in the planned delivery of care for patients with a chronic condition, informed by an enhanced information exchange over and above routine discharge and referral notices”. In the case of diabetes, shared care involves input from a range of health care professionals and a collaborative team approach is essential. The forthcoming National Service Framework (NSF) for diabetes in the UK will undoubtedly argue that the most important person in the team is the patient, who must undertake a responsible role in the constant monitoring of their condition. Over the past three decades many types of shared care systems for diabetes have been tried and tested in the UK. Greenhalgh has systematically reviewed the literature, examining more than fifty schemes (over half of which were unpublished). The main findings were as follows: 1 Established shared care schemes of two types, centralised hospital based and consultant led or decentralised, community based and multidisciplinary. 2 A closely knit steering group or enthusiastic key individual, often the consultant diabetologist, could be clearly identified in all of the published successful schemes. 3 Structured care by primary care physicians with an interest in diabetes and supported by an enthusiastic specialist liaison team to produce comparable and occasionally superior levels of care to those provided solely by the hospital diabetes department. Unstructured care was ineffective and wasteful of resources. 4 Three randomised controlled trials showed that successful share care schemes had two common features – a centralised prompting system for recall and a structured check list for the primary care physician. 5 Successful district wide schemes shared three common features A Extensive planning phase when objectives were clearly defined and the facilities, expertise and commitment of primary care were assessed. B Locally developed written guidelines for the management of diabetes. C A well documented outreach system from the hospital by highly trained nurse facilitators who could advise on practical problems, maintain enthusiasm and enable fast tracking of patients for specialist review. The Fife programme incorporated all of these features. Diabetes is recorded as a cause of death on a minority of death certificates for patients with diabetes. Life years lost for patients with diabetes is strongly related to age at diagnosis and is a means of expressing mortality without relying on accurate prevalence data. The light at the end of the tunnel for these patients is careful control of blood pressure down to a level of 130 over 80 and treatment of other risk factors, particularly aggressive lipid lowering.

Enter the new diabetes website player – diabetesonestop.com

As a diabetes community, we are relatively well catered for electronically. There are many diabetes websites: sites designed for patients, others for healthcare professionals and yet more for researchers. There are society sites, charity sites and a host of general healthcare sites, all providing diabetes information. Why the need for another diabetes site? John Wiley & Sons, publishers of Practical Diabetes International, decided after extensive research into what was currently available on the Internet that there was a valuable role for a central resource for all members of the diabetes community and operated as a “partnership” with them. This electronic resource would aim to offer the full range and depth of information that people living and working with diabetes need. This was the genesis of diabetesonestop.com (Figure 1) Home page of diabetesonestop.com Wiley organised and took on board the feedback from focus group meetings with diabetes professionals, patients and family carers, and people working for the pharmaceutical industry. They set up an Editorial Advisory Board of distinguished (and multidisciplinary) experts, under the Chairmanship of the Editor-in-Chief of this journal. Following close consultation with the Board and a period of closed site testing with patients, professionals and industry, they formally launched diabetesonestop.com on 26 March 2001. Looking round the site a number of characteristics will become apparent to the visitor. First, diabetesonestop.com caters, the publishers believe, for a unique spread of user groups: healthcare providers of all kinds (medical, nursing and other professional), scientists, academics and researchers, individuals and families living with diabetes, and people working in the healthcare industrial sector. The aim is to save the visitor time and trouble in searching across numerous sites on the Internet. The Editorial Advisory Board has already been referred to. The website will operate under the guidance and editorial supervision of this panel of independent experts, representing all the key professions involved in diabetes care, thereby ensuring the quality, reliability, relevance and integrity of its contents. Wiley, as a world-class STM publisher, with over six hundred journals and literally thousands of books under its imprint, including a particularly significant presence in diabetes (Practical Diabetes International, Diabetes/Metabolism Research and Reviews, The International Textbook of Diabetes and a wide range of other diabetes-related print and online titles and products), brings strong additional credentials to the site. Wiley possesses excellent information resources, contacts and expertise in diabetes. By teaming up with diabetes information providers worldwide, the Publishers believe they will be able to offer information that can really be relied on. Obviously, the information requirements of such a large and various audience as ‘the diabetes community’ will differ widely. The contents of diabetesonestop.com will be arranged in such a way as to allow users to find information appropriate to their levels of interest and knowledge quickly and easily. The contents will cover all aspects of diabetes – psycho-social, legal, financial, economic and lifestyle-related as well as medical and scientific – and will interpret the term ‘diabetes’ in the broadest therapeutic sense, including closely-associated clinical areas such as obesity and cardiovascular disease as well as the well-known classical complications of the disease. One of the key features of diabetesonestop.com is its scale. The Publishers point out that it is still very early days but already the breadth and depth of the site are developing fast. A list of some of the main current contents appears in Table 1 and a list of forthcoming features in Table 2. It will be seen that there is a host of resources and services waiting in the wings. diabetesonestop.com has been designed to help all members of the diabetes health care team (in both secondary and primary care sectors) and is committed to supporting best clinical practice in the very fast-changing world of diabetes care. It has elected to do this by involving all those living and working with diabetes, including other bona fide providers of electronic information and services. diabetesonestop.com is opening its arms to all to ensure it delivers comprehensive and unbiased information. The site seeks comments, contributions and suggestions from health professionals, which can be delivered through a variety of feedback features and mechanisms.2 With its emphasis on delivering what you want, we suggest diabetesonestop.com is well worth a visit. www.diabetesonestop.com Feedback features and mechanisms

Maximising health gain within available resources in the New Zealand public health system

Objective: to obtain intervention-condition-specific investment and disinvestment recommendations which optimise the potential for health gain from existing respiratory diseases resource expenditure; and to trial a health economics technique for this purpose, assessing its usefulness as a means of prioritising health services resource allocation. Design: a programme budgeting and marginal analysis (PBMA) exercise drawing upon the expertise of an advisory group of clinicians, managers and consumer advocates, supported by health authority staff. Setting: the Southern and Midland health regions in New Zealand which have populations of one million and seven hundred thousand respectively. Health system context: publicly funded secondary care sector in which regional health authority (RHA) purchasers contract for services with health care providers. Methods: available evidence on the marginal costs and benefits of services for respiratory diseases was examined by an advisory group who produced investment and disinvestment recommendations by consensus using agreed prioritisation criteria. Results: A list of specific investment and disinvestment proposals. Implementation plans for a number of investments formed part of the business plans for both RHAs in 1997/1998. No disinvestments were planned. Conclusions: prioritisation methods like PBMA, which are explicit and rational, can produce defensible evidence-based recommendations with the additional benefit of the credibility and support of an expert advisory group. The process encourages co-operative working and may itself have enduring benefits. However, preparation and conduct of such exercises is resource intensive and requires careful planning. This exercise has provided valuable lessons for the conduct of future prioritisation work.

Population Based Approaches to the Integration of Primary and Secondary Care

Health systems have become increasingly fragmented. Conditions such as diabetes, which require a multidisciplinary approach to care involving both the primary and secondary care sectors, have been particularly affected by the lack of coordination. In order to integrate care around the needs of the patient, a complex process is required to gain agreement on how care should be delivered. Using diabetes as a case study, and by applying the Delphi technique and access to the available evidence, we have shown that patients, doctors, nurses and allied health workers can agree upon the scope of care required for a given clinical scenario and with the criteria for referral between those with different skills. These agreements can form the basis of Care-maps, which in turn allow the definition of gaps in care, required educational materials, needed assessment pro forma, tools for enhancing communication between health workers, and training activities. Existing integrated care approaches in the United Kingdom and the United States, focusing on quality of care rather than resource, have been associated with improvements in health care delivery. Those working in primary care should consider this approach for stimulating enhancements in both clinical quality and efficiency.

The management of osteoarthritis in the third millennium

Osteoarthritis (OA) is already the most common disorder of joints, and is likely to go on increasing in prevalence. Primay prevention, although theoretically possible, is unlikely to occur because it would need major behavioural changes within society as a whole. Similarly, disease control through drugs seems unlikely to be achieved for a disorder that is an age-associated, mechanically driven ?disorder of evolution?. Current treatment is not very effective (with the exception of joint replacement), is dominated by drug therapy, and by the interests of those in the secondary care sector. The information revolution, combined with increasing understanding of the nature of OA, is likely to lead to major changes in management strategies in the future. There may be little of no place for the rheumatologist within future management of OA.

The North Norwegian Health Net.

The North Norwegian Health Net is a comprehensive scheme to connect all health-care institutions in the area to a national computer network. Services available include telemedicine, e-mail and Web access. A general practitioner has responsibility for ensuring that the clinical information is correct. Medical departments are responsible for the content of their own Web pages. All institutions require authorization before connection to ensure data protection and security. Changes in communication between primary- and secondary-care sectors are being monitored. To date the implementation of the network programme has gone smoothly.