Self-perceived oral health and access to care in diabetic and non-diabetic women: A qualitative study

BackgroundAccess to dental care is of growing importance to individuals with chronic illnesses and policymakers alike.ObjectivesTo explore personal views of diabetic and non-diabetic women regarding their oral health and access to dental care.MethodsA qualitative study was performed involving 6 diabetic and 6 non-diabetic female hospital attendees. A thematic framework approach was used to analyze the interviews.ResultsResponses yield three emerging central themes: oral health impact, self-maintained oral health and dental service delivery and costs. Personal views varied particularly in oral health self-perception and visiting the dentist. Certain drawbacks shadowed the quality of care in governmental and private sectors. Response variations were observed among diabetics and non-diabetics.ConclusionWithin the study limits, female hospital attendees had variable responses on how they looked upon their oral health. A variation in oral hygiene practices and visiting the dentist was observed. Participants believed that governmental and private clinics offered high quality care, with high treatment costs in private clinics and long waiting times in the public service being the main drawbacks. Practical Significance: Importance of supporting patients, educating practitioners and alarming policymakers about the impact of oral health problems and access to dental care.     

Community care service for diabetics in the Poole area.

Because of an increasing work load at the hospital diabetic clinic in Poole general practitioners were asked to help in a community care service for diabetics. In this, general practitioners typically care for non-ketotic patients with maturity onset diabetes who are well controlled on diet or diet and oral hypoglycaemic agents, while the clinic concentrates on more difficult cases and screens patients for long-term complications. The hospital laboratory''s work load has been eased because patients may attend for two-hour interval blood sugar estimations when they like; most patients appreciate this flexibility and prefer being looked after by their own doctor. The service has not increased the general practitioners'' work load unduly, but it has heightened their awareness of diabetes in the community, thus allowing the diabetic consultant to deal with the problems for which he has been trained. The service has thus provided improved care for all diabetics in the Poole area.     

Nurse practitioners in primary care. V. Development of the utilization and financial index to measure effects of their deployment.

The new Utilization and Financial Index (UF-Index) was developed to measure the economic effects of deployment of new health professionals or of other changes in the provision of health services. By means of several steps, information on concurrent use of various categories of health service is converted into a single quantitative index. The index has been used to evaluate the financial effects of introduction of nurse practitioners into primary care practices by means of two complementary studies.     

Fifty six continence advisers,one peripatetic teacher.

The increasing demand for the services of a continence nurse led to a novel plan to combat such demand in Leicestershire. The district nursing service seconded a nurse to be trained as an adviser and then to return to the community to set up continence clinics in each health centre. The adviser selected nurses to run these clinics and taught them the skills required to do so. She also carried her own caseload. One hundred and one patients were seen in the clinics in the first year, of whom 30 were cured. In a further one third continence was greatly improved, and the remainder benefited from advice and consultation. The adviser has worked in only six health centres but has had a greater impact on dealing with incontinence than a series of lectures and seminars for district nurses over many years had had.     

Feasibility and effects of nurse run clinics for patients with epilepsy in general practice: randomised controlled trial. Epilepsy Care Evaluation Group.

OBJECTIVE: To test the feasibility and effect of nurse run epilepsy clinics in primary care. DESIGN: A randomised controlled trial of nurse run clinics versus "usual care." SETTING: Six general practices in the South Thames region. SUBJECTS: 251 patients aged over 15 years who were taking anti-epileptic drugs or had a diagnosis of epilepsy and an attack in the past two years who met specified inclusion criteria and had responded to a questionnaire. MAIN OUTCOME MEASURES: Questionnaire responses and recording of key variables extracted from the clinical records before and after the intervention. RESULTS: 127 patients were randomised to a nurse run clinic, of whom 106 (83%) attended. The nurse wrote 28 letters to the general practitioners suggesting changes in epilepsy management. For this intervention group compared with the usual care group there was a highly significant improvement in the level of advice recorded as having been given on drug compliance, adverse drug effects, driving, alcohol intake, and self help groups. CONCLUSIONS: Nurse run clinics for patients with epilepsy were feasible and well attended. Such clinics can significantly improve the level of advice and drug management recorded.     

Depression case management by practice nurses in primary care: an audit

Introduction Depression is a common and debilitating condition. A body of evidence exists about improving depression outcomes in primary care, using collaborative care models. Such approaches, however, have not been routinely adopted within general practice settings. In this paper we outline the results of an audit of an enhanced care initiative that trained practice nurses to deliver such approaches.Method An audit of symptom outcome and satisfaction was conducted in depression case-management clinics run by practice nurses. Results were then benchmarked against appropriate randomised trial data. The cost of practice nurse time devoted to the delivery of the service was estimated by multiplying time by unit cost.Results A mean change of 9.07 (standard deviation (SD) 6.67, 95% confidence interval (CI) 7.93-10.22, P < 0.001) points on the Patient Health Questionnaire (PHQ9) score was observed in those who were using/had used the service. Clinical change demonstrated a shift from moderate-to-severe to mild depression. The results reflect the changes seen in randomised controlled trial data from similar interventions in similar samples, and are superior to expected treatment as usual outcomes. Overall, respondents were 'very satisfied' with the service on offer. The mean cost of practice nurse time was estimated at ￡45 per patient.Discussion While acknowledging the limitations of audit data, practice nurses in general practice appear to be able to offer effective and acceptable case management to patients experiencing depression.     

Structural Barriers to Timely Initiation of Antiretroviral Treatment in Vietnam: Findings from Six Outpatient Clinics

In Vietnam, premature mortality due to AIDS-related conditions is commonly associated with late initiation to antiretroviral therapy (ART). This study explores reasons for late ART initiation among people living with HIV (PLHIV) from the perspectives of health care providers and PLHIV. The study was undertaken in six clinics from five provinces in Vietnam. Baseline CD4 counts were collected from patient records and grouped into three categories: very late initiators (≤100 cells/mm³ CD4), late initiators (100–200 cells/mm³) and timely initiators (200–350 cells/mm³). Thirty in-depth interviews with patients who started ART and 15 focus group discussions with HIV service providers were conducted and thematic analysis of the content performed. Of 934 patients, 62% started ART very late and 11% initiated timely treatment. The proportion of patients for whom a CD4 count was obtained within six months of their HIV diagnosis ranged from 22% to 72%. The proportion of patients referred to ART clinics by voluntary testing and counselling centres ranged from 1% to 35%. Structural barriers to timely ART initiation were poor linkage between HIV testing and HIV care and treatment services, lack of patient confidentiality and a shortage of HIV/AIDS specialists. If Vietnam’s treatment practice is to align with WHO recommendations then the connection between voluntary counselling and testing service and ART clinics must be improved. Expansion and decentralization of HIV/AIDS services to allow implementation at the community level increased task sharing between doctors and nurses to overcome limited human resources, and improved patient confidentiality are likely to increase timely access to HIV treatment services for more patients.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool,GRiST

Aim To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care.Background Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients'' care pathways, within general practice and IAPT services.Methods Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants'' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis.Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems.Conclusions A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.     

Fundholding: a two tier system?

The Calverton practice is one of 30 fundholding practices in Nottinghamshire. Three years after the inception of fundholding, it has achieved a lower outpatient waiting time for its specialist clinics than non-fundholding practices in the region. Its district nursing and health visiting services have been strengthened. Prescribing costs remain below the national average, and making further cost reductions has not been easy. The business plan has allowed the practice to work within a defined budget and develop expertise in the purchasing of services. Through the provision of specialist clinics and increased patient demand the workload of general practitioners has risen by 15% in the past year. But fundholding is still a minority activity in Nottinghamshire--a non-fundholders'' group has been set up to ensure that purchasing of good quality secondary care is equitably distributed among all patients, and this group is extremely active.     

Problems of diabetics in prison.

Providing care for diabetics is difficult in prison. Six diabetic prisoners or former prisoners were seen whose care was difficult or unsatisfactory. Three had multiple admissions to hospital during their sentences with diabetic ketoacidosis that they induced themselves by not taking insulin. The motive seemed to be removal from prison to the fairly pleasant surroundings of the local hospital. A fourth prisoner required admission in a hyperglycaemic, hyperosmolar state that had gone unnoticed as he was thought to be "acting up." The two others had imperfect long term management of diabetes during their sentences. There is clearly room for improvement in diabetic services in British prisons, but manipulative behaviour on the part of some diabetic prisoners may remain a problem.     

Diabetic Clinics Today and Tomorrow: Mini-clinics in General Practice

In the belief that there was need for diabetic clinics in general practice, 14 of them have been started in the Wolverhampton area. Provided that patients with diabetes that is difficult to control, or who need extra care, remain the responsibility of the hospital diabetic department, this system is an advantage for the hospital department, general practice, and the patient. We believe that many patients are now getting better care in general-practice clinics than they were in the hospital department.     

Influences on control in diabetes mellitus: patient,doctor, practice,or delivery of care?

OBJECTIVE--To assess patient, doctor, practice, and process of care variables for their effect on glycaemic control in diabetes mellitus, and to quantify their relative effects. DESIGN--Search of general practice medical records, patient questionnaires and examination, doctor questionnaire, videotaping and analysis of consultations, and practice questionnaire. SETTING--12 practices with 32 participating general practitioners in Nottinghamshire. SUBJECTS--318 patients randomly selected from those with diabetes in each practice, 10 for each participating doctor. MAIN OUTCOME MEASURE--Glycaemic control as measured by random glycated haemoglobin A1c estimation (random haemoglobin A1 measurement). RESULTS--Glycaemic control was significantly related to the disease process as measured by years since diagnosis, treatment group, and number of diabetes related clinical events. Females had significantly worse control than males. Other patient factors, such as age, social class, lifestyle, attitudes, satisfaction, and knowledge, had no association with glycaemic control. Of all the doctor factors examined, only doctors who professed a special interest in diabetes achieved significantly better glycaemic control. Bigger and better equipped practices and those with a diabetic miniclinic had patients with significantly better glycaemic control, as did those with access to dietetic advice. Patients attending hospital clinics had worse glycaemic control, but this seemed to be attributable to the case mix and practice characteristics. Shared care did not contribute to the multiple linear regression model. CONCLUSION--Glycaemic control among diabetic patients in the community is related to such factors as treatment group, sex, and years since diagnosis; it is also related to the organisation and process of care. The findings support concentrating diabetic care on partners with special interests in diabetes in well equipped practices with adequate dietetic support.     

The effect of the health care supply environment on children's nutritional status in rural Nepal

This article examines the effect of access to health infrastructure, personnel and services on children's nutritional status in rural Nepal. Data for the study come from the 1996 Nepal Living Standards Survey, which includes individual- and household-level information on children's nutritional status and its environmental and socioeconomic determinants, and community-level information on the availability of health care infrastructure, personnel and services. The study uses a structural modelling approach to assess the relative contributions of the health care supply environment on children's anthropometric status via the pathway of maternal and child health (MCH) service use. The findings suggest that improvements in the availability of outreach clinics and the structural quality of the closest public facility would be expected to have statistically significant and large effects on the use of MCH services, and that increases in MCH service use would have a statistically significant impact on weight-for-age, but not weight-for-height or height-for-age. The overall impact of the heath care supply environment on nutritional status is assessed through a series of policy simulations.     

Evaluating The Effect of Establishing Protocol for Self- Care Practice of Diabetic Foot Patients Regarding Their Needs,Concerns and Medication Use: A quasi-experimental study

BackgroundThe practice of diabetic self-care plays a significant role in maintaining and preventing diabetic foot complications, but low commitment to self-care practices is common. This study evaluates the effect of establishing protocol for self-care practice of diabetic foot patients according to their needs, concerns, and medication use. A quasi-experimental research (pre-test and post-test) design was used in outpatient clinics at Benha University Hospital, Egypt. The study included 100 adult patients diagnosed with diabetes (types I and II) for at least six months. The findings revealed that 79% suffered from burning or tingling in legs or feet; 74% complained of presence of redness of lower limb, legs or foot pain with activity, and loss of lower extremity sensation; and 80% had changes in skin colour or skin lesions. A comparison between the group pre- and post-intervention (protocol) showed that post-intervention patient foot care knowledge and self-care practice scores were higher. Also, 72% of the participants obtained good knowledge related to foot care post- protocol intervention compared to 37% pre- intervention. Based on the findings, the establishing intervention protocol fosters self-care practice and knowledge regarding needs, concerns, and medication use among diabetic foot patients. Therefore, this protocol can be applied in health practice and research in order to prevent diabetic foot ulcer, and thereby foot amputation.     

Screening for carriers of cystic fibrosis through primary health care services.

OBJECTIVE--To evaluate the uptake of cystic fibrosis carrier testing offered through primary health care services. DESIGN--Carrier testing for cystic fibrosis was offered to patients of reproductive age through primary health care services. SETTING--Three general practice surgeries and four family planning clinics in South West Hertfordshire District Health Authority. SUBJECTS--Over 1000 patients aged 16-44 attending two general practices and four family planning clinics and a stratified random sample of patients aged 16-44 from one general practice''s age-sex register. RESULTS--When screening was offered opportunistically the uptake was 66% in general practice and 87% in family planning clinics. Ten per cent of those offered a screening appointment by letter took up the invitation. Of the screened population, 76% had previously heard of cystic fibrosis, 35% realised it is inherited, and 18% realised that carriers need not have any family history. If they found themselves in an "at risk" partnership 39% would consider not having children and 26% would consider terminating an affected pregnancy, but in each case most people were unsure how they would react. CONCLUSIONS--Most people offered a cystic fibrosis test opportunistically wish to be tested, and the responses of those tested indicate that knowledge of carrier state would be considered in future reproductive decisions.     

Family doctors and innovation in general practice

Family doctors have been presented with changes in government policies and incentives in a recent white paper on primary care. Little work has been done, however, to find out how general practitioners respond to such measures. The response of general practitioners to professional and economic incentives was examined in relation to the location of the practice and the characteristics of the practitioners in seven different areas of England. The areas represented urban, rural, affluent, and deprived communities. The overall response rate was 74%, but the response varied among the areas, being poorest (64%) in an inner city area. Practices were subdivided as innovative, traditional, or intermediate, according to whether they employed a nurse and participated in the cost rent scheme and the vocational training scheme. Innovative practices were defined as fulfilling two of these criteria and traditional practices as fulfilling none; the remainder were classed as intermediate. The results showed that these three types of practice had distinct strategies that were related to financial constraints and the local population. Innovative practices had more partners and were often located in rural or affluent suburban areas; traditional practices had fewer partners and were more common in urban and working class areas. Innovative practices seemed to be in the best position to increase their services, and hence their incomes, in response to the recent proposals in the white paper. Practices in areas of developmental difficulty (predominantly urban but not necessarily inner city areas) had been less able to respond to existing incentives and had a smaller margin available for developing their services.In view of the effect of local constraints of economics and population on the strategy of practices, concentrating resources for primary care in local budgets for working class and urban areas may be preferable to extending the system of charging fees for services provided by family doctors.     

Diabetes registers: a grassroots approach.

OBJECTIVES--To compile a register of diabetic patients within the catchment area of a district general hospital and evaluate the characteristics of the population using aggregated data from a general practice audit. DESIGN--Cross sectional study. Practices identified all known diabetics and completed a questionnaire from information in each patient''s medical record. SETTING--Practices affiliated to a district audit group in south east England. MAIN OUTCOME MEASURES--Number of participating practices; prevalence of diabetes and its complications; and sex distribution of patients, age at diagnosis and review, treatment, and metabolic control. Comparisons with similar data from other studies. RESULTS--41 out of 43 practices participated, and 2574 diabetic patients were identified (prevalence 1.18%). 52.4% of patients were male. The mean age was 61.6 years. 32% of patients were treated with insulin, 51.5% with oral hypoglycaemic agents, 16.5% with diet alone. The mean random blood glucose concentration was 10.4 mmol/l and glycosylated haemoglobin 10.1%. 8% had proteinuria, 7% a history of myocardial infarction, 5% a history of stroke, and 2% a diabetes related amputation. These proportions were not significantly different from those found in studies performed by different methods in Poole, Islington, Powys, Trowbridge, and Southall. CONCLUSION--It is feasible to compile a register of diabetic patients in a district and evaluate their characteristics by using only general practice sources.