Treatment In Secondary Care Research Articles

Outcome of pulmonary rehabilitation in COPD patients with severely impaired health status

IntroductionEffects of pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) patients with severely impaired health status are poorly documented since these patients are usually excluded from clinical trials. This retrospective, observational study aims to study the impact of disease on health status and the effects of PR on COPD patients referred to a tertiary center for PR in The Netherlands.MethodsBetween June 2006 and June 2010, 437 patients with COPD were allocated to our intensive, comprehensive PR program. Patients participated in this interdisciplinary program for 12 weeks for a weekly average of 20–25 hours. Before and directly after, several measures of physical performance and health-related quality of life were determined.ResultsAt baseline, most patients (75%) had a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage of III–IV. Peak exercise performance on a cycle ergometer was on average reduced to 43 ± 29 Watt, and health-related quality of life was significantly impaired, with a total score on the St George’s Respiratory Questionnaire (SGRQ) of 66. Health-care utilization in the year preceding PR was very high. After rehabilitation, all outcome measures improved statistically significantly (P < 0.001). Exercise performance measured with the 6 minute walking distance test improved clinically significantly in 68% of the patients, whereas 75% of the patients showed a clinically meaningful improvement in quality of life as measured with the SGRQ. Multiple regression analysis revealed that 19% of the variation in responses on the 6 minute walking distance test and the SGRQ could be explained on the basis of baseline characteristics.ConclusionThe present study provides data to indicate that COPD patients may substantially benefit from rehabilitation in a tertiary pulmonary rehabilitation center, despite a severely impaired health status and high level of health-care utilization, in which prior treatment in primary and secondary care have failed to improve health status. Individual rehabilitation responses can only partially be predicted on the basis of baseline characteristics. Consequently, no firm conclusions can be drawn from this study with respect to the selection of candidates that could be deemed eligible for this rehabilitation program when entering the program.

Heterogeneity in the treatment of moderately severe scalp psoriasis in Scotland – results of a survey of Scottish health professionals

Background:Scalp psoriasis is a chronic recalcitrant condition. An aging literature for topical treatments used in clinical practice and no treatment guidelines means there is no current gold standard for its management in Scotland. There are no Scottish data on the resources and costs of treatment of the scalp psoriasis patient.Objective:Conduct a survey of Scottish healthcare professionals to understand how patients are typically managed to support the development of a model estimating the cost-effectiveness of a new treatment for moderately severe scalp psoriasis in Scotland.Research design and methods:Experts from primary and secondary care were invited to participate in an interview programme to collect information on the management of scalp psoriasis in Scotland. This was further informed by Scottish prescribing statistics. Simple descriptive statistics were performed.Results:Forty-three healthcare professionals (33 from primary care and ten in secondary care) completed the survey which illuminated national prescribing statistics. While an overall 72% response rate was achieved, representation from five of 14 Health Boards was not available. There was significant variation in stated patient pathways but some common themes. Most patients were treated initially with coal tar preparations and shampoos, then often progressing to topical potent corticosteroids. There was no consensus on the order patients might receive topicals thereafter although if referred for specialist review they would typically have been treated with three topicals in primary care first. Treatment in secondary care comprised application of topicals available in primary care or alternative preparations with nurse assistance to improve compliance. Phototherapy and systemic agents were not given to patients with scalp psoriasis alone. Study limitations are not considered to impact on the study observations.Conclusions:There was a large variety in first-, second- and third-line agents in primary care in scalp psoriasis although our interview programme and prescribing data confirmed which treatments were most frequently prescribed. Treatment heterogeneity reflects the limitations in current therapies, paucity of evidence-based effectiveness data and lack of clinical guidelines. Experts agreed ‘current standard practice’ in Scotland was best described as an average across five plausible treatment pathways.

Management of cough in adults

Educational aimsTo illustrate reasonable and cost-effective management of cough, one of the most frequent reasons for primary care consultations.To assist in the secondary care diagnosis and treatment of chronic cough as the solely presenting symptom if chest radiography and lung function tests remain inconclusive.To emphasise the rational order starting with simple (noninvasive and cost-effective) diagnostic procedures, graduating to complex, invasive and expensive (e.g.computed tomography and bronchoscopy) measures.SummaryCough is highly prevalent as a cumbersome presenting complaint for many patients. The symptom cough is elicited by a myriad of very different respiratory and nonrespiratory diseases. Symptomatic pharmacological treatment is of very limited efficacy. Presently, no new drug for cough in the pipeline has completed phase II development. Therefore, treating cough requires exact diagnosis for causal treatment. Cough is often the first (but not necessarily an early) symptom of life-threatening diseases, such as lung tumours or recurrent pulmonary embolism. Thus, in 2004, the German Respiratory Society published evidence-based guidelines on the management of cough. Acute and chronic cough were defined, and algorithms were provided for diagnostic workup. In 2010, the guidelines were updated (http://leitlinien.net). An abridged english version is also now available [1]. In this review, evidence-based recommendations (mostly weak evidence or consensus) from these guidelines are adapted into learning points.

Randomised controlled trial of the clinical and cost effectiveness of a specialist team for managing refractory unipolar depressive disorder.

BackgroundAround 40 per cent of patients with unipolar depressive disorder who are treated in secondary care mental health services do not respond to first or second line treatments for depression. Such patients have 20 times the suicide rate of the general population and treatment response becomes harder to achieve and sustain the longer they remain depressed. Despite this there are no randomised controlled trials of community based service delivery interventions delivering both algorithm based pharmacotherapy and psychotherapy for patients with chronic depressive disorder in secondary care mental health services who remain moderately or severely depressed after six months treatment. Without such trials evidence based guidelines on services for such patients cannot be derived.Methods/designSingle blind individually randomised controlled trial of a specialist depression disorder team (psychiatrist and psychotherapist jointly assessing and providing algorithm based drug and psychological treatment) versus usual secondary care treatment. We will recruit 174 patients with unipolar depressive disorder in secondary mental health services with a Hamilton Depression Rating Scale (HDRS) score ≥ 16 and global assessment of function (GAF) ≤ 60 after ≥ 6 months treatment. The primary outcome measures will be the HDRS and GAF supplemented by economic analysis incuding the EQ5 D and analysis of barriers to care, implementation and the process of care. Audits to benchmark both treatment arms against national standards of care will aid the interpretation of the results of the study.DiscussionThis trial will be the first to assess the effectiveness and implementation of a community based specialist depression disorder team. The study has been specially designed as part of the CLAHRC Nottinghamshire, Derbyshire and Lincolnshire joint collaboration between university, health and social care organisations to provide information of direct relevance to decisions on commissioning, service provision and implementation.Trial registrationClinical trials.gov identifier NCT01047124

Secondary care treatment of patients with varicose veins in National Health Service England: at least how it appeared on a National Health Service website

This study aimed to assess the trends and regional variations in secondary care treatment of patients with varicose veins in National Health Service (NHS) England based on data published by the Hospital Episode Statistics which was freely and readily available to the public and health-care policy-makers. Hospital Episode Statistics data for patients being treated for varicose veins, and UK Statistics Authority population estimates in all 28 Strategic Health Authorities (SHAs) in England from 2002 to 2006 were retrieved and analysed. Between 2002 and 2006 there was a 20% overall reduction (46,190-37,135) in the total number of varicose vein procedures performed in NHS England per year. The number of varicose vein procedures performed per 100,000 population per year varied significantly across the SHAs (P < 0.0001). Similarly, significant regional variations were also noted in the frequency of primary procedures of greater and small saphenous vein (P < 0.0001). During this time, injection sclerotherapy was only performed in 15 (53.6%) SHAs. The annual proportion of varicose vein procedures performed as daycases had increased from 56% to 64% during the period. From 2002 to 2006 there was an overall reduction in the total number of varicose vein procedures performed in NHS England with major regional variations.

Design and evaluation of a documentation system to support the continuity of pharmaceutical care of day-case oncology patients between hospital and community pharmacists

Abstract Objective Survey and analysis of pharmaceutical care issues (PCIs) occurring during the course of chemotherapy. Feedback from future users to design and test a documentation system to facilitate information transfer between hospital and community pharmacists. Setting Day-case chemotherapy clinics at the Edinburgh Cancer Centre, community pharmacies providing palliative care services and community pharmacies used by patients recruited to the survey. Method Prospective cross-sectional cohort survey of PCIs in 90 day-case patients receiving chemotherapy. The identified PCIs and the interview transcripts from one-to-one interviews with six local specialist community pharmacists informed the design of the patient medication profile (PMP), the use of which was tested in 20 patients. Two postal questionnaires were used: one to 153 pharmacists in other UK cancer centres/units, one to 20 community pharmacists involved in the testing of the PMP. Key findings Of the 271 recorded PCIs in 90 patients, 41% (112/271) PCIs were identified for the transfer of care and were mostly associated with supportive medication prescribed to manage chemotherapy toxicities. In the testing of the PMP, 88 PCIs were identified in 20 patients and 59% (52/88) of PCIs judged relevant to continuity of care were documented on the PMP and transferred via the patient to community pharmacists together with an information sheet and questionnaire. Seventy-five percent (15/20) of pharmacists replied to the questionnaire, indicating they had followed up 52% (27/52) of all transferred PCIs. ‘Lack of time’ was the only reason given by community pharmacists for not following up PCIs. The majority of community pharmacists thought the information received was useful and increased their contribution to patient care. Conclusion Although oncology patients receive treatment in secondary care, almost half of the associated PCIs require follow-up in primary care between cycles of chemotherapy. The PMP was considered supportive to community pharmacists in the continuity of pharmaceutical care of these patients. The study helped to define the next stage of the development work which requires to define patients' needs and to test a system in practice. Community pharmacists' expectations and requirements must be part of the continuing development of the seamless provision of pharmaceutical care to this patient group.

A patient's diary: episode 24 — From the electronic portfolio of Dr Sally T Greengage

Objective 1: A case study from general practice. Why have I chosen this objective for my plan? The uncertainties of general practice continue to puzzle me. Some of the patients are extremely difficult to diagnose. It is even more difficult to satisfy their needs and make them happy. Furthermore there is often a conflict between these two goals. I decided that by studying the most difficult patient in the practice in depth I would be able to learn more about not only his individual case but the whole nature of general practice. Which patient have I chosen? I have chosen Mr Geoffrey Norman Gland (age: 55 years). How will I go about putting my learning plan in to action? I shall study all the patient's records and summarise his history, diagnoses, investigation results, and episodes of treatment in secondary care. I shall look at the ways in which psychological and cultural factors may have had an impact on his health and health beliefs. I shall record his current narrative for analysis using grounded theory. I shall explore his various illness beliefs and see if any of them has any ‘scientific’ substance. Have steps been taken to protect him from the risk factors to which he may be exposed? I shall look at ways in which the practice and the profession may have failed to understand and meet his needs, bearing in mind current theory and best practice in the areas of somatisation, personality disorder, communications skills, narratology, and patient-centred medicine. I shall consider whether we have sufficiently explored his mind for hidden agenda material. In considering his symptom presentations, have we sufficiently valued his own contribution? (NB: Answer probably yes to both). I shall note the effects that the patient's emotions inevitably have on the feelings of myself and the …

Specialised in-patient treatment for severe, chronic, resistant obsessive-compulsive disorder

Aims and MethodA naturalistic study was conducted to examine the outcome on self-report and observer-rated measures in patients with severe, chronic, resistant obsessive–compulsive disorder (OCD) admitted to a specialised in-patient unit.ResultsTwenty-six patients were admitted over the study period. The mean age of all patients was 37 years (s.d.=13.8, range 18–61 years) and they had a mean duration of OCD of 18.4 years (s.d.=10.9, range 4–40 years). Instruments measuring severity demonstrated a 37–67% reduction in obsessive–compulsive symptoms and a 64% reduction in depressive symptoms after an average of almost 15 weeks in hospital.Clinical ImplicationsThis study demonstrates that specialised in-patient care can benefit a small group of severely ill patients with OCD who fail to respond to treatment in primary and secondary care.

Specialised in-patient treatment for severe, chronic, resistant obsessive–compulsive disorder

Aims and MethodA naturalistic study was conducted to examine the outcome on self-report and observer-rated measures in patients with severe, chronic, resistant obsessive–compulsive disorder (OCD) admitted to a specialised in-patient unit.ResultsTwenty-six patients were admitted over the study period. The mean age of all patients was 37 years (s.d.=13.8, range 18–61 years) and they had a mean duration of OCD of 18.4 years (s.d.=10.9, range 4–40 years). Instruments measuring severity demonstrated a 37–67% reduction in obsessive–compulsive symptoms and a 64% reduction in depressive symptoms after an average of almost 15 weeks in hospital.Clinical ImplicationsThis study demonstrates that specialised in-patient care can benefit a small group of severely ill patients with OCD who fail to respond to treatment in primary and secondary care.

The Pattern and Progression of Lower Urinary Tract Symptoms after Transurethral Prostatectomy Compared with Those Seen in the General Population

ObjectivesMen undergoing transurethral prostatectomy (TURP) often have some level of residual symptoms after this operation. Reliance on symptom scores to assess outcomes means there is relatively little information on the exact pattern of such symptoms. The aim of this study was to describe the pattern, progression, and associated bother of lower urinary tract symptoms after TURP. MethodsDetailed information on urinary symptoms, prostatectomy status, and associated bother was obtained from a randomly selected sample of community-dwelling men by using a postal questionnaire. Rates of individual urinary symptoms in the postprostatectomy population were calculated, and compared with those in the background population and those in secondary care. ResultsOf 7640 men who responded, 422 had undergone prostatectomy. Symptom levels remained significantly higher in the postoperative group than the background population, with 19.4% experiencing four or more symptoms on a weekly basis. The pattern of symptoms was similar to that seen in the general population.Men in the post-TURP group experienced greater levels of bother when symptom level (odds ratio: 2.69; 95%CI, 1.80–4.01) was controlled. Both symptom and bother, however, were significantly lower than those in people referred for secondary care treatment of their symptoms. ConclusionsMen with a previous prostatectomy still report high levels of urinary symptoms and appear to experience greater levels of bother from these symptoms than men in the general population.

A description of health care provision and access to treatment for women with urinary incontinence in Europe — A five-country comparison

Background Female urinary incontinence is a prevalent condition, but only about one-third of women seek treatment. Objectives To describe the health care provision for women with urinary incontinence from a European perspective, selecting France, Germany, Spain, Sweden, and the United Kingdom as examples, and to investigate whether specific barriers for treatment exist. Methods Available health care system information, a literature review and clinical expert information identified patterns of treatment provision. Results In Spain, Sweden, and the UK, access to medical care in general is primarily through the general practitioners. However, in Spain and Sweden, women with urinary incontinence can directly visit specialists. In France and Germany, women have equal access to either general practitioners or specialists. Aside from general practitioners, gynaecologists play a major role in urinary incontinence care in all countries except the UK. In Germany, urologists are also involved in initial female urinary incontinence care; however, only in about 16% of women. There are no waiting lists in France and Germany for appointments with physicians or procedures, contrary to Spain, which has long waiting lists. Access to general practitioners in the UK is unrestricted whereas advanced diagnosis and treatment in secondary care requires long waits. A specific Swedish policy mandates that no woman is required to wait longer than 3 months for incontinence visits and related surgery. In Sweden and the UK, specialist nurses and other health care workers provide incontinence services. Almost all treatment options for urinary incontinence are at least in part reimbursed. However, various co-payments and fees in France, Germany, Spain and Sweden exist and constitute out-of-pocket expenses for women if no complementary additional private health insurance is available. In some countries, financial incentives for physicians to provide incontinence services are low, raising concerns about their interest to engage in continued patient care. Conclusions Information about service provision in Europe for women with urinary incontinence is limited and makes it difficult to understand barriers to treatment seeking. A broad European perspective may promote optimised treatment access in the future for this widespread and under-recognised condition.

Unmet need for joint replacement: a qualitative investigation of barriers to treatment among individuals with severe pain and disability of the hip and knee.

To explore barriers to health-care utilization in respondents with moderate to severe hip/knee symptoms of pain and disability. In-depth interviews were carried out with 27 participants who had high levels of hip/knee pain and disability (according to New Zealand scores). There were 10 men and 17 women; median age 76 yr (range 51-91). The data were analysed thematically using the constant comparison technique. Three types of barrier were identified: (i) people's own perceptions of need and reluctance to seek treatment, (ii) perceptions and experiences of primary care and (iii) experiences of treatment in secondary care. Pessimism about availability of treatments, and concerns about effectiveness and risks of surgery, made older people reluctant to seek medical help. Such views were often confirmed by GPs. Some of those referred to a hospital specialist were told that they were too young or too mobile for surgery. Barriers to treatment and unmet need for joint replacement exist in the UK, particularly amongst older people.

Search for occult secondary osteoporosis: impact of identified possible risk factors on bone mineral density.

To determine whether the use of more elaborate diagnostic tests can identify possible risk factors for secondary osteoporosis and to evaluate the impact of these possible risk factors on the severity of bone disease in the study population. Cross-sectional study. We have investigated 377 subjects (285 females, 92 males) with osteoporosis (T-score less than -2.5 in dual energy X-ray absorption) or nontraumatic lumbar vertebral fractures; these patients were referred to our hospital, a secondary care centre, for evaluation and treatment of osteoporosis. Osteoporosis without attributable risk factor was diagnosed in 106 women (37%) and 30 men (33%). In 241 patients (179 women, 62 men) one or more possible risk factors for osteoporosis (in this paper also called subclinical disease) were revealed. The most common were lactose malabsorption, disturbed exocrine pancreatic function and renal tubular disturbances, including renal hypercalciuria, incomplete renal tubular acidosis and mild phosphate diabetes. The number of possible risk factors in the individual patient was significantly related to the severity of osteoporosis as assessed by Z-scores (Spearman correlation r = -0.43, P < 0.001, n = 172 for females; r = -0.28, P < 0.05, n = 65 for males). All the identified subclinical diseases would have remained undetected if the currently accepted guidelines for the investigation of patients with osteoporosis were applied. The statistically significant correlation between the number of identified possible risk factors and the severity of bone disease in the individual patient strongly suggests the pathogenetic significance of the identified subclinical diseases. It is yet to be shown, whether specific treatment of these subclinical diseases yields additional improvement of bone mass as compared with standard treatment of osteoporosis.

The United Kingdom National Service Framework For Older People—One Year On

The National Health Service (NHS) has provided health care in the United Kingdom since 1948. Funding is by central taxation so that all consultations and treatment in primary (community) and secondary (hospital) care are free at the point of delivery to the individual. The NHS structure remained almost unchanged for its first 25 years, but latterly, under first the Conservative government, and now under Labour, the pace of change is increasing. In a previous article we described one of the organizational changes introduced by Labour—the Primary Care Trust. 1 In this article, another aspect of the present government’s reforms, the National Service Frameworks (NSF) are discussed. One of the first of these was that for Older People. 2 It was introduced a year ago and it is hoped that this description of the document and its impact in the United Kingdom will be of interest to North American readers. NATIONAL SERVICE FRAMEWORKS: A NEW CONCEPT Shortly after taking office in 1997, the Labour government published a “White Paper” called The New NHS: Modern, Dependable outlining its plan for reorganization of health services. 3 A further update was published in July 2000. 4 There were six stated important principles that underpinned the proposed changes:

Ejercicio de la Medicina Interna en América Latina: Rol de médico internista

This article explores the causes of the crisis in the role of internists. As in the United States, the progressive specialization of internists lead to a dehumanized, expensive and technical practice of medicine. Aiming to better incomes and prestige, more than 60% of internists practice as specialists. Primary care physicians, with a very low rate of problem solving, cover 75% of consultations. Specialists, with increasing costs, cover the rest of consultations. Patients, medical schools and health organizations are claiming the return of the general internal medicine specialist. To increase the interest for general internal medicine, several strategies are applicable. Medical students interested in general internal medicine could receive a focused training, provided by these specialists. A greater emphasis should be put on primary care. More independent, secondary care diagnostic and treatment centers, should be created. Continuous medical education should be done with periodical re certification of physicians. The public health system should increase its wages and the generalist view should be maintained by physicians when practicing at their private offices.

Estimating a population's needs for the treatment of lower urinary tract symptoms in men: what is the extent of unmet need?

Prevalence surveys have shown that men aged over 40 commonly experience lower urinary tract symptoms (LUTS). However, such studies cannot be used in isolation to inform health service planning, as not all men are troubled by their symptoms nor would they necessarily benefit from treatment. A total of 3,540 randomly selected men in Somerset were sent a postal questionnaire containing the American Urological Association (AUA) symptom index. Men reporting moderate or severe symptoms were invited for clinical assessment to determine whether they could benefit from treatment in primary or secondary care. The impact of their symptoms on their quality of life was measured using the ICS-QOL questionnaire. The prevalence of reported LUTS was 256 per 1,000 men aged 40 and over. Of men reporting moderate or severe urinary symptoms, 40 per cent considered that they did not interfere with their life at all. The results were used to estimate the number of men with moderate or severe urinary symptoms, who could benefit from treatment and whose symptoms affected their quality of life. In a population of 250,000, 482 men [95 per cent confidence interval (CI) 263-704] could benefit from treatment in secondary care, and 3,557 men could be managed in primary care through watchful waiting or medical intervention (95 per cent CI 2,935-4,182). The majority of men with LUTS in the community are not greatly troubled by them and are unlikely to benefit from treatment. This work can be used as a basis for planning the provision of services across primary and secondary care for the treatment of this common condition.

Transferring the costs of expensive treatments from secondary to primary care

General practitioners, especially fundholders, are becoming increasingly concerned about being asked to prescribe treatments for their patients that are outside their therapeutic experience. They are concerned about the clinical responsibility for such prescribing and the effects on their budgets. In some specialties transferring the costs of expensive treatments from secondary to primary care (cost shifting) has become partly institutionalised because of the separate sources of funding for drugs prescribed in the two sectors. With increased efforts to control the rising costs of the drugs budget and the emergence of new expensive treatments, cost shifting will be a challenge to clinicians and purchasers as they strive for rational, cost effective prescribing. A review of the funding mechanisms for drugs prescribing and of the relation between the licensing process and the decision to support the use of a treatment in primary or secondary care is needed.