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General Medical Services (general + medical_services)
Selected AbstractsThe value of a specialist lipid clinicINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 6 2008S. C. Martin Summary Aims:, To establish the value of the first 3 years of a cardiovascular risk factor clinic in tackling the major risk factors for cardiovascular disease (CVD). Methods:, A database review of all 339 patients referred to the clinic. Results:, Blood pressure levels in the hypertensive patients were significantly reduced and 9% of the smokers managed to quit for 12 months, half of them subsequently relapsing. Ninety-eight oral glucose tolerance tests were performed and 40% were abnormal yielding 10 patients with hitherto unsuspected diabetes and 29 with impaired glucose tolerance. Sixty-four of the 97 referrals of patients in the primary prevention group (no evidence of CVD) were found to have calculated Framingham coronary heart disease risk estimates of < 15% per decade, the lowest being 0.3%. Lipid levels were significantly reduced in both the hypercholesterolaemic (n = 290) and hypertriglyceridaemic (n = 49) patient groups through the use of more potent statins, extensive use of combination therapy and appropriate use of fibrates and omega-3 fish oil supplements. The annual drug cost per patient treated only increased from £310.72 to £398.08, yet there was a 3.5-fold increase in the number of patients achieving the General Medical Services 2 target of a total cholesterol < 5 mmol/l and a 4.5-fold increase in patients achieving the Joint British Societies 2 target of a low-density lipoprotein (LDL) cholesterol < 2 mmol/l. Conclusion:, The need for a specialist clinic was demonstrated by the 66% of primary prevention referrals who did not meet the current NICE treatment threshold. Additionally, the clinic was able to diagnose and treat 39 patients with undiagnosed diabetes mellitus/impaired glucose tolerance and 12 with hypothyroidism. LDL cholesterol was reduced overall by 36% implying a greater than one-third reduction in future cardiovascular events before the improvements in blood pressure control and smoking cessation are included and this was achieved at marginal extra cost to the mean drug bill at referral. [source] Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical IllnessJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2008Cynthia M. Boyd MD OBJECTIVES: To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge. DESIGN: Observational. SETTING: Tertiary care hospital, community teaching hospital. PARTICIPANTS: Older (aged ,70) patients nonelectively admitted to general medical services (1993,1998). MEASUREMENTS: Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point. RESULTS: By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover. CONCLUSION: For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated. [source] Factors associated with discussion of care plans and code status at the time of hospital admission: Results from the Multicenter Hospitalist Study,JOURNAL OF HOSPITAL MEDICINE, Issue 6 2008Andrew D. Auerbach MD Abstract BACKGROUND: Hospital admission is a time when patients are sickest and also often encountering an entirely new set of caregivers. As a result, understanding and documenting a patient's care preferences at hospital admission is critically important. OBJECTIVE: To understand factors associated with documentation of care planning discussions in patients admitted to general medical services at 6 academic medical centers. DESIGN: Observational cohort study using data collected during the Multicenter Hospitalist Study, conducted between July 1, 2002 and June 30, 2004. SETTING: Prospective trial enrolling patients admitted to general medicine services at 6 university-based teaching hospitals. PATIENTS: Patients were eligible for this study if they were 18 years of age or older, admitted to a hospitalist or nonhospitalist physician, and able to give informed consent. MEASUREMENTS: Presence of chart documentation that the admitting team had discussed care plans with the patient within the first 24 hours of hospitalization. Notations such as "full code" were not counted as a discussion, whereas notations such as "discussed care wishes and plan with patient" were counted. RESULTS: A total of 17,097 patients over the age of 18 gave informed consent and completed an interview and chart abstraction; of these, 1776 (10.3%) had a code status discussion (CD) documented in the first 24 hours of their admission. Patients with a CD were older (69 years vs. 56 years, P < 0.0001), more often white (52.8% vs. 43.3%, P < 0.0001), and more likely to have cancer (19.8% vs. 11.4%, P < 0.0001), or depression (35.1% vs. 30.9%, P < 0.0001). There was marked variability in CD documentation across sites of enrollment (2.8%-24.9%, P < 0.0001). Despite strong associations seen in unadjusted comparisons, in multivariable models many socioeconomic factors, functional status, comorbid illness, and documentation of a surrogate decision maker were only moderately associated with a CD (adjusted odds ratios all less than 2.0). However, patients' site of enrollment (odds ratios 1.74-5.14) and informal notations describing prehospital care wishes (eg, orders for "do not resuscitate"/"do not intubate;" odds ratios 3.22-11.32 compared with no preexisting documentation) were powerfully associated with CD documentation. Site remained a powerful influence even in patients with no documented prehospital wishes. LIMITATIONS: Our results are derived from a relatively small number of academic sites, and we cannot connect documentation differences to differences in patient outcomes. CONCLUSIONS: Documentation of a CD at admission was more strongly associated with informal documentation of prehospital care wishes and where the patient was hospitalized than legal care planning documents (such as durable power of attorney), or comorbid illnesses. Efforts to improve communication between hospitalists and their patients might target local documentation practices and culture. Journal of Hospital Medicine 2008;3(6):437,445. © 2008 Society of Hospital Medicine. [source] Caring for people with learning disability: a survey of general practitioners' attitudes in Southampton and South-west HampshireBRITISH JOURNAL OF LEARNING DISABILITIES, Issue 1 2000Ken SteinArticle first published online: 24 DEC 200 The aim of the present paper was to examine general practitioners' (GPs') beliefs about: the demands made on the primary care team by people with learning disability; their confidence in meeting health care needs and perceived training requirements; attitudes towards specialist or generic health service provision, and current contact with specialist teams; and attitudes towards screening in people with learning disability. A postal questionnaire was sent to a randomly selected partner from 95% of the practices in the Southampton and South-west Hampshire Health District. Forty-eight (75%) GPs responded and few were undecided about the demands placed on primary care teams, but beliefs were mixed. Most GPs were confident in dealing with the medical care needs of people with learning disability and the majority felt that training courses would not be worthwhile, except to learn more about specialist services where contact was very low and a ,link worker' scheme had had little apparent impact. Most respondents agreed that GPs should meet the medical needs of people with learning disability as part of general medical services and approximately half had a positive attitude towards providing regular health checks. Respondents were cautious about offering cervical cancer screening to women with learning disability. A small minority suggested that they would take no action to follow up a non-attendance for mammography. As a heterogeneous population, it is not surprising that GPs' attitudes vary widely. Further research is required to establish the nature and scale of demands made on primary health care teams, and to evaluate systematic means of addressing health care needs of people with learning disability. [source] | ||||||||||