Improving compliance with requirements on junior doctors' hours

Problem Compliance with UK regulations on junior doctors'' working hours cannot be achieved by manipulating rotas that maintain existing tiers of cover and work practices. More radical solutions are needed.Design Audit of change.Setting Paediatric night rota in large children''s hospital.Key measures for improvement Compliance with regulations on working hours assessed by diary cards; workload assessed by staff attendance on wards; patient safety assessed through critical incident reports.Strategies for change Development of new staff roles, followed by change from a partial shift rota comprising 11 doctors and one senior nurse, to a full shift night team comprising three middle grade doctors and two senior nurses.Effects of change Compliance with regulations on working hours increased from 33% to 77%. Workload changed little and was well within the capacity of the new night team. The effect on patient care and on medical staff requires further evaluation.Lessons learnt Reduction of junior doctors'' working hours requires changes to roles, processes, and practices throughout the organisation.     

The health and cost effects of substituting home care for inpatient acute care: a review of the evidence

BACKGROUND: There is much interest in reducing hospital stays by providing some health care services in patients'' homes. The authors review the evidence regarding the effects of this acute care at home (acute home care) on the health of patients and caregivers and on the social costs (public and private costs) of managing the patients'' health conditions. METHODS: MEDLINE and HEALTHSTAR databases were searched for articles using the key term "home care." Bibliographies of articles read were checked for additional references. Fourteen studies met the selection criteria (publication between 1975 and early 1998, evaluation of an acute home care program for adults, and use of a control group to evaluate the program). Of the 14, only 4 also satisfied 6 internal validity criteria (patients were eligible for home care, comparable patients in home care group and hospital care group, adequate patient sample size, appropriate analytical techniques, appropriate health measures and appropriate costing methods). RESULTS: The 4 studies with internal validity evaluated home care for 5 specific health conditions (hip fracture, hip replacement, chronic obstructive pulmonary disease [COPD], hysterectomy and knee replacement); 2 of the studies also evaluated home care for various medical and surgical conditions combined. Compared with hospital care, home care had no notable effects on patients'' or caregivers'' health. Social costs were not reported for hip fracture. They were unaffected for hip and knee replacement, and higher for COPD and hysterectomy; in the 2 studies of various conditions combined, social costs were higher in one and lower in the other. Effects on health system costs were mixed, with overall cost savings for hip fracture and higher costs for hip and knee replacement. INTERPRETATION: The limited existing evidence indicates that, compared with hospital care, acute home care produces no notable difference in health outcomes. The effects on social and health system costs appear to vary with condition. More well-designed evaluations are needed to determine the appropriate use of acute home care.     

Blame the Patient,Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

Objective

Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.

Method

Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.

Results

Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.

Conclusion

Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.     

Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution

BackgroundThe outbreak of SARS in 2003 had a dramatic effect on the health care system in Toronto. The main objective of this study was to investigate the psychosocial effects associated with working in a hospital environment during this outbreak.MethodsQuestionnaires were distributed to all willing employees of Sunnybrook and Women''s College Health Sciences Centre between Apr. 10 and 22, 2003. The survey included questions regarding concern about SARS, precautionary measures, personal well-being and sociodemographic characteristics; a subsample also received the 12-item version of the General Health Questionnaire (GHQ-12).ResultsOf the 4283 questionnaires distributed, 2001 (47%) were returned, representing 27% of the total hospital employee population of 7474. The proportions of respondents who were allied health care professionals, nurses and doctors and who worked in areas other than patient care were representative of the hospital staff population as a whole. Of the 2001 questionnaires, 510 contained the GHQ-12. Two-thirds of the respondents reported SARS-related concern for their own or their family''s health. A total of 148 respondents (29%) scored above the threshold point on the GHQ-12, indicating probable emotional distress; the rate among nurses was 45%. Masks were reported to be the most bothersome infection control precaution. Logistic regression analysis identified 4 factors as being significantly associated with increased levels of concern for personal or family health: perception of a greater risk of death from SARS (adjusted odds ratio [OR] 5.0, 95% confidence interval [CI] 2.6–9.6), living with children (adjusted OR 1.8, 95% CI 1.5–2.3), personal or family lifestyle affected by SARS outbreak (adjusted OR 3.3, 95% CI 2.5–4.3) and being treated differently by people because of working in a hospital (adjusted OR 1.6, 95% CI 1.2–2.1). Four factors were identified as being significantly associated with the presence of emotional distress: being a nurse (adjusted OR 2.8, 95% CI 1.5–5.5), part-time employment status (adjusted OR 2.6, 95% CI 1.2–5.4), lifestyle affected by SARS outbreak (adjusted OR 2.2, 95% CI 1.4–3.5) and ability to do one''s job affected by the precautionary measures (adjusted OR 2.9, 95% CI 1.9–4.6).InterpretationOur findings indicate that the SARS outbreak had significant psychosocial effects on hospital staff. These effects differed with respect to occupation and risk perception. The effect on families and lifestyle was also substantial. These findings highlight the need for interventions to address psychosocial distress and concern and to provide support for employees during such crises.During the spring of 2003, Toronto was in the midst of the first of 2 phases of a SARS outbreak. As the principal tertiary referral hospital, Sunnybrook and Women''s College Health Sciences Centre (SWC) admitted 71 patients with SARS, of whom 23 were health care workers, between Mar. 14 and May 24. Over 1000 patients were seen at the SWC SARS assessment clinic.The effect of SARS on the health care system in the greater Toronto area was dramatic.^1,2,3,4,5,6 At various times during the outbreak, 3 hospitals were closed. Health care workers were at increased risk and many were quarantined, which resulted in severe staff shortages. On Mar. 28, following the closure of a second hospital, new and intensive infection control directives were issued for all hospitals in the greater Toronto area and surrounding area. At SWC the directives included cancellation of all hospital-based outpatient clinics, significant visitor restrictions, mandatory wearing of surgical masks by all staff at all times (and N95 masks in patient care areas), limited hospital entrance and mandatory screening of everyone entering the building (symptom/exposure questionnaire and temperature reading). Health care workers were instructed to work at 1 health care institution only, and off-work contact between health care workers from different institutions was discouraged. The SWC SARS Management Team met daily to implement Ministry of Health directives, organize care of patients with and without SARS and deal with staffing issues. With clinic and operating room closures and quarantined staff, staff redeployment to screening at entrances and other essential services became necessary. After Apr. 17, staff not involved in patient care no longer had to wear masks; however, most of the other infection control directives were kept in place well into the summer months.Little is known about the psychological effects of this type of disease outbreak on health care and other hospital workers. Maunder and colleagues¹ described the experiences of a small number of patients and staff at a Toronto hospital during the initial SARS outbreak. They observed that the staff were fearful for their own and their family''s health and found caring for colleagues as patients emotionally difficult. Mitchell and associates⁷ reported increased feelings of stigmatization among nurses during an outbreak of vancomycin-resistant enterococci in a hospital in Australia; feelings of alienation and isolation were also noted. A literature review revealed no large, systematic studies of the effect of a disease outbreak on hospital staff, particularly in cases with a high risk of nosocomial spread, as is the case with SARS.^2,4,8,9,10The main objectives of this study were (a) to determine the self-reported psychosocial effects associated with working in a hospital environment during the peak of a disease outbreak, specifically psychological distress and effects on the work and personal lives of employees, and (b) to examine the determinants of these effects.     

Where is the silver lining? Anxious doctors ask.

When Nova Scotia elected a Liberal government in September 1993, a wave of optimism washed over the province''s medical community. One of their own, Dr. John Savage, was now premier, and another, Dr. Ron Stewart, was minister of health. However, anticipation soon turned to anger as Stewart took aim at physician fees and hospital costs to help reduce the province''s health care budget by $62 million. Last November, relations between him and the Medical Society of Nova Scotia (MSNS) hit bottom. In an uncharacteristically political move, the society launched an ad campaign featuring slogans such as "Death by 1000 cuts" and "Uncle Sam want me. Ron Stewart doesn''t." Four months later, the health department and the MSNS called a truce, with an agreement that many physicians consider a positive step. Today the province and its doctors are speaking again, and the medical society is working hard to help define physicians'' roles in a new, regionalized health care system. But has the mood of doctors really improved? Last spring, CMAJ interviewed a cross section of Nova Scotia physicians to find out.     

A Qualitative Exploration of Workarounds Related to the Implementation of National Electronic Health Records in Early Adopter Mental Health Hospitals

Aims

To investigate the perceptions and reported practices of mental health hospital staff using national hospital electronic health records (EHRs) in order to inform future implementations, particularly in acute mental health settings.

Methods

Thematic analysis of interviews with a wide range of clinical, information technology (IT), managerial and other staff at two early adopter mental health National Health Service (NHS) hospitals in London, UK, implementing national EHRs.

Results

We analysed 33 interviews. We first sought out examples of workarounds, such as delayed data entry, entering data in wrong places and individuals using the EHR while logged in as a colleague, then identified possible reasons for the reported workarounds. Our analysis identified four main categories of factors contributing to workarounds (i.e., operational, cultural, organisational and technical). Operational factors included poor system integration with existing workflows and the system not meeting users'' perceived needs. Cultural factors involved users'' competence with IT and resistance to change. Organisational factors referred to insufficient organisational resources and training, while technical factors included inadequate local technical infrastructure. Many of these factors, such as integrating the EHR system with day-to-day operational processes, staff training and adequate local IT infrastructure, were likely to apply to system implementations in various settings, but we also identified factors that related particularly to implementing EHRs in mental health hospitals, for example: EHR system incompatibility with IT systems used by mental health–related sectors, notably social services; the EHR system lacking specific, mental health functionalities and options; and clinicians feeling unable to use computers while attending to distressed psychiatric patients.

Conclusions

A better conceptual model of reasons for workarounds should help with designing, and supporting the implementation and adoption of, EHRs for use in hospital mental health settings.     

The health of Indians in Canadian cities: a challenge to the health care system

It is well known that Canadian native people living on reserves have high morbidity and mortality rates, but less is known about the health of those who migrated to urban centres. Several studies have shown that these people have high rates of mental health problems, specific diseases, injuries, infant death and hospital admission. In addition, there is evidence that cultural differences create barriers to their use of health care facilities. The low socioeconomic status, cultural differences and discrimination that they find in cities are identified as the primary blocks to good health and adequate health care. More epidemiologic studies need to be done to identify health problems, needs and barriers to health care. Federal, provincial and civic governments along with the appropriate departments of faculties of medicine should begin working with native organizations to improve the health of native people living in Canada''s cities.     

Patient-orientated gastroenterology.

Analysis of the first year''s working of a combined gastroenterology clinic in a district hospital has shown that the major benefit was improved patient management. Hospital attendances were reduced, the diagnostic process accelerated, and unnecessary radiological investigations and surgical operations avoided. There were no obvious major disadvantages.     

Grampian Health Board's joint drug formulary.

OBJECTIVE--To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN--A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board''s medicines committee for approval and distribution. SETTING--Grampian Health Board. SUBJECTS--Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE--Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS--The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day''s treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS--A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board''s expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.     

Audit of surgical practice in a community hospital.

The results of a prospective analysis of one year''s surgery on inpatients in a busy community hospital showed that a high quality of surgery may be achieved with safety and low rates of complications. The results of a retrospective analysis of certain aspects of surgery was just as encouraging. Surgery that is performed in a community hospital is convenient for the patient, provides continuity of care by the general practitioner, and waiting list times are short. Surgical facilities can form an integral part of the comprehensive service provided by a community hospital and can lighten the caseload for minor surgery at the district general hospital. Close liaison between the two hospitals is essential.     

应激模型的生理学基础及其比较研究进展

各种外界因素如创伤、手术、感染、缺氧、强光、噪音等通过一定强度作用于机体可以引起机体特异性和非特异性反应,非特异性反应与刺激因素性质无直接关系,称为应激(stress)。近年来,随着社会的发展,生活节奏的加快、自然环境和生活环境的恶化,应激已经成为威胁人类健康的重要因素,有关应激影响机体健康的研究备受国内外学者的重视,而合适的应激动物模型的建立对应激研究的顺利开展有着重要意义。本文就目前应激动物模型的病理生理特点、种类、制作和评价方法等进行综述,旨在为应激研究提供参考。     

The confederation worm token.

To an increasing degree the psychiatrist is oriented to the community and general hospital either as consultant, therapist, or collaborator in overall patient management. In these new roles, he becomes a more comprehensive physician and also conveys psychiatric insights to his colleagues.Psychological factors and the patient''s personality “style” influence the development and course of every disease, complicating diagnosis and effective treatment. It is a basic requirement that a good working alliance be established between patient and physician. This is assisted by comprehensive history taking, which clarifies the lifesetting in which the illness began, the patient''s personality and his habitual reactions of emotional regression under stress. It will also point up errors introduced by the patient, omissions, and distortions in offering the subjective data which the physician must evaluate.Seven major personality types and appropriate physician responses are outlined: the dependent demanding oral patient, the orderly controlled obsessive, the dramatic seductive hysteric, the long-suffering masochist, the querulous paranoid, the overbearing narcissist and the aloof withdrawn schizoid.The non-psychiatrist can resolve complex and puzzling medical problems if he has an increased awareness of how emotional forces complicate illness and if he can exploit comprehensive history taking to the full.     

Factors and Models Associated with the amount of Hospital Care Services as Demanded by Hospitalized Patients: A Systematic Review

Background

Hospitals are constantly being challenged to provide high-quality care despite ageing populations, diminishing resources, and budgetary restraints. While the costs of care depend on the patients'' needs, it is not clear which patient characteristics are associated with the demand for care and inherent costs. The aim of this study was to ascertain which patient-related characteristics or models can predict the need for medical and nursing care in general hospital settings.

Methods

We systematically searched MEDLINE, Embase, Business Source Premier and CINAHL. Pre-defined eligibility criteria were used to detect studies that explored patient characteristics and health status parameters associated to the use of hospital care services for hospitalized patients. Two reviewers independently assessed study relevance, quality with the STROBE instrument, and performed data analysis.

Results

From 2,168 potentially relevant articles, 17 met our eligibility criteria. These showed a large variety of factors associated with the use of hospital care services; models were found in only three studies. Age, gender, medical and nursing diagnoses, severity of illness, patient acuity, comorbidity, and complications were the characteristics found the most. Patient acuity and medical and nursing diagnoses were the most influencing characteristics. Models including medical or nursing diagnoses and patient acuity explain the variance in the use of hospital care services for at least 56.2%, and up to 78.7% when organizational factors were added.

Conclusions

A larger variety of factors were found to be associated with the use of hospital care services. Models that explain the extent to which hospital care services are used should contain patient characteristics, including patient acuity, medical or nursing diagnoses, and organizational and staffing characteristics, e.g., hospital size, organization of care, and the size and skill mix of staff. This would enable healthcare managers at different levels to evaluate hospital care services and organize or reorganize patient care.     

The impact of a new geriatric program in a hospital for the chronically ill.

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country''s health care system prompted experimental changes in the operation and training procedures at St. Mary''s of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a district inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of patinets being discharged home after shorter stays. This may be one avenue for deceleration of our country''s dismal rate of institutionalization.     

Integration of working environment into life cycle assessment framework

Background, aim, and scope  Life cycle assessment (LCA) has been considered one of the tools for supporting decision-making related to the environmental aspects of a product system. It has mainly been used to evaluate the potential impacts associated with relevant inputs and outputs to/from a given product system throughout its life cycle. In most cases, LCA has not considered the impacts on the internal environment, i.e. working environment, but only the external environment. Recently, it has been recognized that the consideration of the impacts on the working environment as well as on the external environment, is needed in order to assess all aspects of the effects on human well-being. To this end, this study has developed a total environmental assessment methodology which enables one to integrate both the working environment and the external environment into the conventional LCA framework. Materials and methods  In general, the characteristics of the impacts on the external environment are different from those on the working environment. In order to properly integrate the two types into total environmental impacts, it is necessary to define identical system boundaries and select impact category indicators at the same level. In order to define the identical system boundary and reduce the uncertainties of LCI results, the hybrid IOA (input–output analysis) method, which integrates the advantages between conventional LCI method and IOA method, is introduced to collect input and output data throughout the entire life cycle of a given product. For the impact category indicators at the endpoint level, LWD (Lost Work Days) is employed to evaluate the damage to human health and safety in the working environment, while DALY (disability-adjusted life years) and PAF (Potentially Affected Fraction) are selected to evaluate the damage to human health and eco-system quality in the external environment, respectively. Results and discussion  The environmental intervention factors (EIFs) are developed not only for the data categories of resource use, air emissions, and water emissions, but also for occupational health and safety to complete a life cycle inventory table. For the development of the EIFs on occupational health and safety, in particular, the number of workers affected by i hazardous items and the number of workers affected at the i magnitude of disability are collected. For the characterization of the impact categories in the working environment, such as occupational health and safety, the exposure factors, effect factors, and damage factors are developed to calculate the LWD of each category. For normalization, the normalization reference is defined as the total LWD divided by the total number of workers. A case study is presented to illustrate the applicability of the proposed method for the integration of the working environment into the conventional LCA framework. Conclusions  This study is intended to develop a methodology which enables one to integrate the working environmental module into the conventional LCA framework. The hybrid IOA method is utilized to extend the system boundary of both the working environment module and the external environment module to the entire life cycle of a product system. In this study, characterization models and category indicators for occupational health and safety are proposed, respectively, while the methodology of Eco-indicator 99 is used for the external environment. In addition to aid further understanding on the results of this method, this study introduced and developed the category indicators such as DALY, and LWD, which can be expressed as a function of time, and introduced PAF, which can be expressed as a probability. Recommendations and perspectives  The consideration of the impacts not only on the external environment, but also on the working environment, is very important, because the best solution for the external environment may not necessarily be the best solution for the working environment. It is expected that the integration of occupational health and safety matters into the conventional LCA framework can bring many benefits to individuals, as well as industrial companies, by avoiding duplicated measures and false optimization.     

Observational Study Assessing Demographic,Economic and Clinical Factors Associated with Access and Utilization of Health Care Services of Patients with Multiple Sclerosis under Treatment with Interferon Beta-1b (EXTAVIA)

Multiple sclerosis (MS) results in an extensive use of the health care system, even within the first years of diagnosis. The effectiveness and accessibility of the health care system may affect patients'' quality of life. The aim of the present study was to evaluate the health care resource use of MS patients under interferon beta-1b (EXTAVIA) treatment in Greece, the demographic or clinical factors that may affect this use and also patient satisfaction with the health care system. Structured interviews were conducted for data collection. In total, 204 patients (74.02% females, mean age (SD) 43.58 (11.42) years) were enrolled in the study. Analysis of the reported data revealed that during the previous year patients made extensive use of health services in particular neurologists (71.08% visited neurologists in public hospitals, 66.67% in private offices and 48.53% in insurance institutes) and physiotherapists. However, the majority of the patients (52.45%) chose as their treating doctor private practice neurologists, which may reflect accessibility barriers or low quality health services in the public health system. Patients seemed to be generally satisfied with the received health care, support and information on MS (84.81% were satisfied from the information provided to them). Patients'' health status (as denoted by disease duration, disability status and hospitalization needs) and insurance institute were found to influence their visits to neurologists. Good adherence (up to 70.1%) to the study medication was reported. Patients'' feedback on currently provided health services could direct these services towards the patients'' expectations.     

七氟烷对糖尿病心肌缺血/再灌注损伤的影响

糖尿病是一种常见病、多发病,严重威胁着人类的健康。现已明确,糖尿病是冠心病发病的一个重要因素。心肌缺血/再灌注(ischemia/reperfusion,I/R)损伤是临床常见的病理过程,同时是冠心病发病及心肌血运重建治疗过程中的核心环节,如何减轻I/R损伤一直是国际研究热点之一。糖尿病与I/R损伤对心肌都有损害作用,相关研究证明糖尿病能够进一步恶化I/R损伤对心肌的损伤作用。研究表明,缺血预处理(ischemia preconditioning,IPC)可以延缓或减轻心肌I/R损伤,同时,麻醉药预处理(anesthetic induced preconditioning,APC)也具有IPC样的心肌保护作用。其中,七氟烷作为现阶段临床较常用的吸入麻醉药,同样对心肌I/R损伤具有保护作用。本文就七氟烷对糖尿病心肌I/R损伤的影响及其机制做一综述。     

电子病历系统在医院信息管理系统中应用初探

电子病历系统是通过计算机等电子设备为载体,对医院患者的诊疗活动进行数字化记录的软件。电子病历中详细记录了医嘱、病程、过敏史、影像检查结果、出院记录等多项医疗数据。电子病历完整、系统、科学地记录了患者身体健康情况以及历次就诊记录,通过一个维度将患者内部不同层次的信息有机的联系在一起。与传统的纸张病历相比,电子病历可以迅速实现不同时间、不同医院医疗信息的高效整合以及信息共享,为临床诊疗提供大量科学准确的信息,大大提高医院的服务效率。本文通过电子病历系统在医院信息管理系统中的应用情况进行简要分析,以期提高电子病历系统在临床中解决实际医疗问题的能力。     

General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey.

OBJECTIVES: To evaluate general practitioners'' knowledge of a range of psychosocial problems among their patients and to explore whether doctors'' recognition of psychosocial problems depends on previous general knowledge about the patient or the type of problem or on certain characteristics of the doctor or the patient. DESIGN: Multipractice survey of consecutive adult patients consulting general practitioners. Doctors and patients answered written questions. SETTING: Buskerud county, Norway. SUBJECTS: 1401 adults attending 89 general practitioners during one regular working day in March 1995. MAIN OUTCOME MEASURES: Doctors'' knowledge of nine predefined psychosocial problems in patients; these problems were assessed by the patients as affecting their health on the day of consultation; odds ratios for the doctor''s recognition of each problem, adjusted for characteristics of patients, doctors, and practices; and the doctor''s assessment of previous general knowledge about the patient. RESULTS: Doctors'' knowledge of the problems ranged from 53% (108/203) of "stressful working conditions" to 19% (12/63) of a history of "violence or threats." Good previous knowledge of the patient increased the odds for the doctor''s recognition of "sorrow," "violence or threats," "substance misuse in close friend or relative," and "difficult conflict with close friend or relative." Age and sex of doctor and patient, patient''s educational level and living situation, and location of practice influenced the doctor''s awareness. CONCLUSIONS: Variation in the patients'' communication abilities, the need for confidence in the doctor-patient relationship before revealing intimate problems, and a tendency for the doctors to be entrapped by their expectations may explain these findings.     

The FOLLOWPACE study: a prospective study on the (cost-)effectiveness of routine follow-up visits in patients with a pacemaker

In the Netherlands, following implantation of a pacemaker (PM) commonly two or three out-patient follow-up visits are scheduled in the first year to check the patient''s health and the PM programme, in order to guarantee optimal patient outcome. Anually, about 200,000 follow-up visits of 20 minutes are performed, in total about 80,000 working hours. The question arises whether and to what extent these regular follow-up checks are truly necessary for the prognosis of the patient and whether they are cost-effective. Yet no information is available on how frequently and extensively a routine PM follow-up visit should be performed. This is probably because it is largely unknown which factors — either documented at PM implantation or at the follow-up visits - predict the occurrence of complications. The FOLLOWPACE study is designed to address these issues. Below we briefly discuss the rationale, objectives and expected results of FOLLOWPACE.