End-stage renal disease: factors affecting referral decisions by family physicians in Canada, the United States, and Britain.

The objective of this study is to determine how patient age, sex, creatinine level, and comorbidity affect referral decisions for the treatment of end-stage renal disease (ESRD) and whether these decisions are affected by physician characteristics in three countries: Canada, the United States, and Britain. A vignette-based questionnaire was mailed to a random sample of family physicians in Ontario, Canada (1,818 physicians); all family physicians in the state of New York (1,814 physicians); and a sample of general practitioners from the south of England (2,228 physicians) in 1996. Physicians were presented with clinical scenarios involving a patient with varying degrees of renal insufficiency and a complicating comorbidity, including angina, diabetes, cancer, mental illness, or socioeconomic circumstances. They were asked to indicate the likelihood of referral. Half the physicians received a questionnaire describing a male patient, and half, a female patient. Mean creatinine levels at which physicians would refer were 260 micromol/L for British physicians, 297 micromol/L for Canadian physicians, and 340 micromol/L for American physicians. No difference in referral rates was found based on the sex of the patient or physician. Sixty-five percent of American and Canadian physicians would refer regardless of patient age, but only 49% of British physicians would do so. Family physicians in the United States, Canada, and Britain function as gatekeepers for patients with ESRD. They are less likely to refer based on increasing severity of comorbid conditions. They also discriminate based on age, but not sex.

A randomized trial of quality assurance in nursing homes.

Sixty nursing homes were randomly allocated to receive or not to receive a quality assurance intervention. The experimental intervention included the use of predeveloped quality assurance packages, the services of a quality assurance consultant, and the process of working through the quality assurance cycle with one of two principal indicator conditions. Two prevalent health problems, hazardous mobility and constipation, were selected as the principal indicator conditions. To detect co-intervention, one of two hidden secondary indicator conditions (potential skin breakdown and urinary incontinence) was assessed in each facility. In the control nursing homes, both the principal and secondary indicator conditions were hidden from staff. The care for 1,525 residents was examined before and after the intervention using a retrospective record review initiated for the study purposes. Improvement in management of the principal conditions, hazardous mobility and constipation, was greater in the experimental group (P less than 0.03 and P less than 0.005, respectively). Neither group changed its management of the hidden conditions. Behavior change was achieved using quality assurance-linked interventions. Further research should focus on refining quality assurance interventions that provide staff education and motivational strategies.

Health, functional, and social status of an elderly primary-care population.

Non-institutionalized family-practice patients aged 75 years or older were screened at home by nurse practitioners using a comprehensive health-assessment instrument. A majority of subjects showed no serious impairment of physical, psychological, or social functioning. An élite minority experienced excellent health.

A pilot home-based geriatric health screening project in primary care.

Regular multidimensional screening of the elderly for undetected health problems has the potential for delaying functional deterioration and improving the quality of life, but has not been evaluated rigorously. This pilot study examined the amount and type of unmet health care need discovered by home-based screening of 100 family practice patients aged 75 and over. Although 96 per cent of patients had some health problems, only 71 per cent had problems that needed further intervention. Of these, the majority were problems in the area of psychosocial function, independence, and lifestyle. Age, sex, and frequency of attendance at the practice in the previous year were not found to be useful markers for targeting screening efforts. Although it is potentially beneficial for detecting unmet need, home-based screening is resource-intensive and requires further examination in randomized trials in the North American context.

Pharmacists and their relationship with elderly patients.

A survey of 60 randomly selected pharmacists explored their relationship with elderly patients, including their information storage systems, dispensing practices and the major problems they encounter with these patients. Nearly all the pharmacists kept a medication profile for each elderly patient, and one third used a computer, which facilitated recording of additional information. However, few recorded the age of the patient. Many pharmacists counselled their elderly patients on the correct use of medications, but few provided counselling on the use of nonprescription drugs. Most of the pharmacists reported using techniques to improve compliance among elderly patients. More than 80% of the pharmacists reported apparently inappropriate prescribing by physicians at least occasionally.