Can telemedicine be used to improve communication between primary and secondary care?

OBJECTIVE: To test feasibility and acceptability of teleconferencing routine outpatient consultations. DESIGN: Exploratory trial of teleconferenced outpatient referrals of general practitioners. SETTING: An inner city teaching hospital and surrounding general practices. SUBJECTS: Six general practices linked to hospital outpatient clinics. MAIN OUTCOME MEASURES: Levels of participants'' satisfaction measured with self administered questionnaires. RESULTS: 54 teleconsultations were performed in 10 different specialties. Few serious technical problems were encountered, and high levels of satisfaction with the consultations were reported by patients, hospital specialists, and general practitioners. CONCLUSIONS: Teleconferenced consultations for routine outpatient referrals with joint participation of general practitioner were feasible. These may have an important potential benefit for improving communication between primary and secondary care.     

Commissioning a national programme of research and development on the interface between primary and secondary care.

The first call for applications to the NHS research and development programme on the interface between primary and secondary care was advertised in February 1994. A total of 674 outline proposals were submitted and 54 (8%) secured funding. Projects have been commissioned in 16 of the 21 priority areas and around 6m pounds has been committed. Analysis shows that multidisciplinary applications are more likely to be funded and that the odds for a successful application are on average nearly doubled for each discipline represented up to five. A survey of applicants and peer reviewers found satisfaction with much of the commissioning process, but peer review and feedback were subject to criticism, particularly by unsuccessful applicants. The programme shows that it is possible to commission a large number of projects in an innovative area of research and development and has identified refinements that will further increase the efficiency and acceptability of the process.     

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.     

Equity in the NHS. Monitoring and promoting equity in primary and secondary care.

Although need is often assumed to be the most important factor in determining the use of health services, there are many inequities in the provision and use of NHS services in both primary and secondary care. For example, existing data from district child health information services have been combined with census data for small areas to show wide variations in immunisation rates between affluent and deprived areas. Purchasers of health care are already responsible for assessing health needs and evaluating services, and the process of monitoring equity is a logical extension of these activities. Routine data sources used to collect activity data in both primary and secondary care can be used to assess needs for care and monitor how well these needs are met. Purchasers and providers should collaborate to improve the usefulness of these routine data and to develop a framework for monitoring and promoting equity more systematically.     

A comparison between primary and secondary toe-to-hand transplantation

Although primary toe-to-hand transplantation is performed with increasing frequency, its use is still controversial because of the lack of any comparative studies documenting its safety and efficacy. Between August of 1990 and December of 1993, 175 consecutive toe-to-hand transplantations for crush and avulsion injuries were performed in 122 patients. The average interval between injury and primary reconstruction was 7 days, and the average interval between injury and secondary reconstruction was 10.7 months. Follow-up ranged from 18 to 91 months, with an average follow-up of 58 months. There were 31 primary transplantations and 144 secondary transplantations. The survival rate was 96.8 percent (30 of 31) for primary reconstruction and 96.5 percent (139 of 144) for secondary reconstruction. Intraoperative anastomotic revision was necessary in 3.2 percent (one of 31) of primary transplantations and 7.6 percent (11 of 144) of secondary transplantations. Three primary toe-to-hand transplantations (9.7 percent) and 17 secondary toe-to-hand transplantations (11.8 percent) were re-explored in the postoperative period. Each group had one superficial infection. The infection rate was 6.5 percent and 0.7 percent in the primary and secondary groups, respectively. Other complications included partial skin loss, which occurred in one patient (3.2 percent) in the primary group and six patients (4.2 percent of 144 transplantations) in the secondary group. Secondary procedures to improve function were necessary in six secondary transplantations (4.2 percent) and in none of the primary transplantations. There was no statistical difference between the two groups in terms of survival, intraoperative anastomotic revision, re-exploration, future secondary procedure, infection, and complications. This series demonstrates that primary toe-to-hand transplantation can be performed in the suitable candidate safely with as much success as secondary reconstruction. Primary toe transplantation can potentially reduce the overall period of recovery and rehabilitation, allowing the patient to return to work sooner. Further study to evaluate and compare the final functional outcome and return to work time between primary and secondary toe-to-hand transplantation is needed.     

Microscopy of the junctional region between human coronal primary and secondary dentine.

The juction between human primary dentine and regular and irregular secondary dentine was examined with a number of different light and electron microscopic techniques. In decalcified material, a narrow band along the innermost surface of the primary dentine stained intensely. The walls of the tubules within the band stained intensely, whereas the tubular walls within the bulk of the primary dentine were not stained. Generally, the walls of the tubules in both types of secondary dentine were also preferentially stained. Although not readily apparent in ground sections, observations of thin sections revealed a dramatic reduction in the number of tubules in regular secondary dentine. Generally, the radiodensity of the intertubular matrix was the same in primary and secondary dentine and the intensely stained band was not seen radiographically. The pulpal ends of the tubules in primary dentine were often occluded with a material having the same radiodensity as peritubular matrix. Both patent and occluded tubules were seen in irregular secondary dentine. Scanning electron microscopy of acid-etched specimens of secondary dentine revealed that some tubules had irregular walls of highly mineralized matrix which was less acid-soluble then the peritubular matrix of primary dentine.     

Control of sulfur partitioning between primary and secondary metabolism

Sulfur is an essential nutrient for all organisms. Plants take up most sulfur as inorganic sulfate, reduce it and incorporate it into cysteine during primary sulfate assimilation. However, some of the sulfate is partitioned into the secondary metabolism to synthesize a variety of sulfated compounds. The two pathways of sulfate utilization branch after activation of sulfate to adenosine 5'-phosphosulfate (APS). Recently we showed that the enzyme APS kinase limits the availability of activated sulfate for the synthesis of sulfated secondary compounds in Arabidopsis. To further dissect the control of sulfur partitioning between the primary and secondary metabolism, we analysed plants in which activities of enzymes that use APS as a substrate were increased or reduced. Reduction in APS kinase activity led to reduced levels of glucosinolates as a major class of sulfated secondary metabolites and an increased concentration of thiols, products of primary reduction. However, over-expression of this gene does not affect the levels of glucosinolates. Over-expression of APS reductase had no effect on glucosinolate levels but did increase thiol levels, but neither glucosinolate nor thiol levels were affected in mutants lacking the APR2 isoform of this enzyme. Measuring the flux through sulfate assimilation using [(35) S]sulfate confirmed the larger flow of sulfur to primary assimilation when APS kinase activity was reduced. Thus, at least in Arabidopsis, the interplay between APS reductase and APS kinase is important for sulfur partitioning between the primary and secondary metabolism.     

Setting priorities for research and development in the NHS: a case study on the interface between primary and secondary care.

Since 1991 the NHS has attempted to identify and prioritise its needs for research and development in a systematic manner. This has not been done before and there is little evidence on which to draw. Multidisciplinary expert groups have identified priorities in different topics using explicit criteria and after widespread consultation within the NHS and research community to identify pressing problems and opportunities for research. This paper focuses on a review completed in 1993 to identify research and development priorities for the NHS in relation to the interface between primary and secondary care. The review covered several recent developments which require evaluation. The authors describe the process used to identify research and development priorities in this complex subject and examine the strengths and weaknesses of the approach. This case study should help to stimulate a wider debate on methods of identifying priorities, particularly those using participatory approaches, in research and non-research contexts.     

The secondary importance of primary health care in South Cameroon

Primary health care in Cameroon meets with serious obstacles. The state gives it a low priority in its budget and over-all policy. The health institutions are rarely active in this field. Institutions which do practice some primary health care are usually foreign. The villagers, finally, are little interested. They insist only on improvement of curative services and material life conditions. The conclusion is that primary health care is regarded as something of secondary importance. First comes a better life. The research for this paper was conducted in 1980 in the South of Cameroon.     

Prenatal genetic counseling for hemoglobinopathy carriers: a comparison of primary providers of prenatal care and professional genetic counselors.

Health personnel trained in medical genetics are insufficient to meet the demand for genetic services. Methods must be found to enable primary care providers to offer commonly needed genetic services themselves. In our recently reported community-wide prenatal screening program for hemoglobinopathies, 36% of women detected to have a hemoglobinopathy did not come to a tertiary center for counseling and thus may have not benefited from testing. To determine whether the efficiency of the program could be increased if counseling were provided by the prenatal care provider (obstetrician or family practitioner), we developed a pilot training program on the basis of our experience in offering such services and enlisted 68% of regional prenatal care providers to participate. The proportion of patients detected to have a hemoglobinopathy who received counseling was similar in the primary and tertiary provider groups: 59% versus 50%, respectively, for sickle trait, and 69% versus 66%, respectively, for beta-thalassemia trait. Knowledge after counseling was also similar for the primary and tertiary provider groups: 64% versus 66% (mean % correct), respectively, for sickle trait, and 79% versus 78%, respectively, for beta-thalassemia trait. However, the two provider groups significantly differed with regard to whether or not the patient had her partner tested. For sickle trait, it was 25% for the primary providers but 49% for the tertiary providers (P < .001). For beta-thalassemia trait, it was 47% for the primary providers but 78% for the tertiary providers (P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Symplastic communication between primary and developing lateral roots of Arabidopsis thaliana

The functional symplastic connections between primary and developinglateral roots of Arabidopsis were studied non-invasively usingconfocal laser scanning microscopy (CLSM), following ester-loadingof the phloem with carboxyfluorescein (CF). Prior to the formationof lateral primordia in the pericycle, the phloem of the primaryroot behaved as an isolated conducting domain. However, thedifferentiation of phloem connector elements within the dividingpericycle allowed the rapid establishment of intercellular communicationbetween the phloem and the cells of the lateral primordium.This communication was often established prior to the completeemergence of the lateral root from the parent root. Shortlyafter its emergence, functional conducting phloem became differentiatedwithin the developing lateral root. A progressive isolationbetween the phloem and surrounding cells at the base of thelateral root was observed as the lateral continued to grow;the new phloem conducting CF to the elongation zone where itwas unloaded symplastically from the protophloem into surroundingcells of the cortex and stele, a feature mirroring the patternfound near the apex of growing primary roots. Anomalous patternsof intercellular communication were found which indicated thatpreviously functional symplastic pathways may have become sealedoff following the emergence of some of the lateral roots. Key words: Arabidopsis, carboxyfluorescein, confocal laser scanning microscopy (CLSM), intercellular transport, lateral roots, phloem (unloading), symplast