Effect of a geriatric consultation service on management of patients in an acute care hospital.

Elderly patients present particular management challenges. We conducted a randomized clinical trial of the effect of a geriatric consultation service on the management of elderly patients in an acute care hospital. A total of 113 patients aged 75 years or more who met certain criteria were assigned to either receive (57 patients) or not receive (56) care by the service. At the end of their hospital stay the patients were assessed with regard to predetermined outcomes. The patients were followed up for 1 year after discharge to determine death rates and direct health care expenditures. The intervention group showed significantly greater improvement in mental status (p less than 0.01), were receiving fewer medications at discharge (p less than 0.05) and had lower short-term death rates (p less than 0.05) than the control group. A geriatric consultation service can improve the hospital care and health of the elderly.     

Unemployment and patterns of consultation with the general practitioner.

The relation between unemployment and consultations with the general practitioner was investigated among 13,275 economically active men aged 18-64 by using the British general household surveys. Men who were unemployed but seeking work consulted with doctors significantly more (odds ratio 1.83; 95% confidence interval 1.61 to 2.09) than those in employment, the highest consultation rate being among those who had been out of work for five years or more (odds ratio 2.12; 95% confidence interval 1.12 to 3.78). The high consultation rates persisted even after adjustment for self reported longstanding illness (odds ratio 1.53; 95% confidence interval 1.34 to 1.76). These findings suggest that in areas with high unemployment general practitioner workload is likely to be high.     

Psychiatric consultation in the nursing home. An inquiry among Amsterdam nursing home physicians

Psychiatric disorders are common among nursing home residents. However, little is known about psychiatric consultation in Dutch nursing homes. As an exploration of the topic, Amsterdam-based nursing home physicians were asked to rate a number of aspects of psychiatric consultation as performed in their nursing home. Striking differences are reported between 14 participating nursing homes with regard to the intensity of psychiatric consultation and the number of consultation requests, which seems low compared with the perceived psychiatric problems. Somatically ill and psychogeriatric residents are estimated to generate an equal number of consultation requests. Psychiatric consultation appears to be characterized by diagnostic clarification, medication recommendations and behavioral management advice whereas staff-directed activities are scarce. Physicians report shortcomings in psychiatric skills among care staff. Research is necessary concerning the psychiatric care delivered to nursing home residents, as well as with regard to the optimal model for psychiatric consultation services. Integration of psychiatric care in nursing homes with mental health care services appears to be desirable.     

An evaluation of home visiting of patients by physicians in geriatric medicine

The practice of preadmission home visiting of patients referred to geriatric medicine units has in recent years been criticised as being unnecessary on the grounds that if there is no waiting list there is no need for allocation of priority for admission; as being wasteful of doctors'' time; as being resented by general practitioners; and as failing to provide adequate clinical information. The geriatric medicine department at the City Hospital with no waiting list for patients referred by general practitioners has retained home visits for most referrals because of the advantages in terms of acceptability to general practitioners (98-100%); the quantity and quality of information obtained; the usefulness of this information in deciding appropriate management and in planning discharge from hospital; and the provision of a unique teaching opportunity, which is highly valued by students and teachers alike.     

Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial

BACKGROUND: Timely recognition and prevention of health problems among elderly people have been shown to improve their health. In this randomized controlled trial the authors examined the impact of preventive home visits by a nurse compared with usual care on the outcomes of frail elderly people living in the community. METHODS: A screening questionnaire identified eligible participants (those aged 70 years or more at risk of sudden deterioration in health). Those randomly assigned to the visiting nurse group were assessed and followed up in their homes for 14 months. The primary outcome measure was the combined rate of deaths and admissions to an institution, and the secondary outcome measure the rate of health services utilization, during the 14 months; these rates were determined through a medical chart audit by a research nurse who was blind to group allocation. RESULTS: The questionnaire was mailed to 415 elderly people, of whom 369 (88.9%) responded. Of these, 198 (53.7%) were eligible, and 142 consented to participate and were randomly assigned to either the visiting nurse group (73) or the usual care group (69). The combined rate of deaths and admissions to an institution was 10.0% in the visiting nurse group and 5.8% in the usual care group (p = 0.52). The rate of health services utilization did not differ significantly between the 2 groups. Influenza and pneumonia vaccination rates were significantly higher in the visiting nurse group (90.1% and 81.9%) than in the usual care group (53.0% and 0%) (p < 0.001). INTERPRETATION: The trial failed to show any effect of a visiting nurse other than vastly improved vaccination coverage.     

Asthma care in Darley Dale: general practitioner audit.

OBJECTIVE--To complete a first audit cycle of asthma care in Darley Dale after starting an asthma clinic. DESIGN--Pre-clinic (1989) and post-clinic (1990) analysis of medical records of patients with asthma. SETTING--A group practice in Derbyshire. PATIENTS--161 pre-clinic, 238 post-clinic patients with asthma. MAIN OUTCOME MEASURES--Term "asthma" in the patient''s computerised problem list, recording of peak expiratory flow rate, smoking history, clinical review, medication, and hospital admissions for asthma. RESULTS--There were significant improvements post-clinic with respect to the term "asthma" in the computer file (1989, 93/161 (58%); 1990, 233/238 (98%) (difference 0.40; 95% confidence interval 0.32 to 0.48)); at least one peak flow measurement (1989, 24/161 (15%); 1990, 143/238 (60%) (0.45; 0.37 to 0.53)); three or more peak flow measurements (1989, 15/161 (9%); 1990, 40/238 (17%) (0.08; 0.02 to 0.14)); and smoking history (1989, 24/161 (15%); 1990, 133/238 (56%) (0.41; 0.33 to 0.49)). There were no significant differences post-clinic with respect to asthma reviewed at least once (1989, 61/161 (38%); 1990, 74/238 (31%) (0.07; -0.03 to 0.17)); recording long term medication; treating acute asthma; or ratio of average to best peak flow rate of 38 patients who had one or more measurements (1989, 31/38 (82%); 1990, 34/38 (89%) (0.08; -0.08 to 0.24)). CONCLUSIONS--Setting up an asthma clinic resulted in better recording of data relevant to patients with asthma. However, objective improvement in patients'' asthma could not be detected. Renewed emphasis on prophylactic measures may result in measurable improvement in these patients'' asthma in the future.