Healthcare quality in an international setting.

This report discusses the process used by the Healthcare Quality Certification Board to internationalize its certification program. With some modifications this methodology can be utilized to define the role of any healthcare professional and to legitimize, create or restructure a certification program that assesses competency in a particular healthcare field. This process and the importance of quality management are related to today's cataclysmic healthcare environment which challenges efforts to confront cost and access.

Trends in diabetes mellitus mortality in Puerto Rico: 1980-1997.

OBJECTIVE: To determine the characteristics and trends of diabetes mortality among the Puerto Rican population from 1980 through 1997. METHODS: Death certificates for Puerto Rican residents whose underlying cause of death was diabetes mellitus (ICD-9-250.0) were reviewed, and sociodemographic information was abstracted. The proportion mortality ratio (PMR) and 95% confidence intervals were calculated by gender, age group, educational level and period of time. Trend analysis in mortality was performed using a Poisson regression model. RESULTS: A total of 26,193 deaths (5.8%) were primarily attributed to diabetes mellitus in the study period. Females accounted for 55.8% of all diabetes related deaths. Diabetes accounted for a higher proportion of deaths among persons aged 60-64 years (8.14%), persons aged 65-74 (8.12%), females (7.73%) and those with 1-6 years of education (7.08%). The PMR steadily increased from 4.55% in the 1980-85 period to 6.91% in the 1992-97 period. There was a higher mortality in male diabetic subjects aged < or = 64 than in females during the 18 year period. Between 1980 and 1991, females aged 65-74 had a higher mortality than males, however, mortality increased in males of the same age group during 1992-97. When the oldest age group (> or = 75) was examined, males had a higher mortality between 1986 and 1997, whereas females had a slightly higher rate between 1980 and 1985. CONCLUSIONS: Our results indicate that diabetes mortality has been markedly increasing in the Puerto Rican population, primarily in persons aged 65 years or more. Further analysis is needed to evaluate the determinants of mortality in diabetes.

[Basic components in the development of research proposals in health sciences]. / Componentes básicos para el desarrollo de propuestas de investigación en las ciencias de la salud.

Any investigation in the health sciences should have a plan or proposal to answer a specific research question. This document, designed for persons preparing for or already pursuing a research project, describes the conceptual framework related with a research proposal, from the study design until its implementation. The objective of this document is to summarize different theoretical aspects that should be considered in a research project, including pertinent references that might be used to deepen the discussion. First, a series of definitions related to the scientific method are presented and then the processes to carry out a research proposal including common epidemiologic designs are illustrated. In addition, a series of research questions that can serve as a guide to perform a critical analysis of published papers are included. Finally, an interdisciplinary group integrated by health professionals with the clinical expertise and health professionals with the necessary skills in biostatistics and epidemiology to undertake a sound scientific research is recommended.

Epidemiology of pediatric AIDS in Puerto Rico: 1981-1998.

The objective of this study was to describe the AIDS-defining conditions (ADC) and survival experience of pediatric AIDS cases (< 13 years age) reported in Puerto Rico. A descriptive analysis of the data gathered by the Puerto Rico AIDS Surveillance System was performed. Data for the 377 pediatric AIDS cases reported from January 1981 through June 1998 were reviewed. Survival curves following AIDS diagnosis were estimated using the Kaplan--Meier method and differences between curves were assessed by the Wilcoxon test. The majority (61%) of the cases were diagnosed before 2 years of age, and nearly 94% of them acquired the infection through perinatal transmission. The most common ADC were Pneumocystis carinii pneumonia (PCP) (23%), wasting syndrome (19.4%), and esophageal candidiasis (19.1%). The overall median survival time during the study period was 53.5 (95% CI: 38.0-106.2) months. Children < 1 year of age had a significantly shorter median survival time compared with older ages (p < 0.05). The survival experience in children diagnosed with PCP, pulmonary candidiasis, cytomegalovirus, and lymphocytic interstitial pneumonia (LIP) was significantly different (p < 0.05) to those children not diagnosed with these conditions. Although patients diagnosed after 1990 showed a median survival time longer than those diagnosed prior to 1990, the difference did not reach statistical significance (p > 0.05). The frequency of several ADC and median survival time of Puerto Rican children differed from those reported in the United States. This may reflect differences in diagnostic procedures or reporting practices.

Epidemiologic profile of AIDS among Puerto Rican women in the San Juan Standard Metropolitan Statistical Area, 1981-1995.

This article describes the epidemiologic profile of Puerto Rican women affected by AIDS in the San Juan Standard Metropolitan Statistical Area (SMSA). Information from AIDS cases reported to the Puerto Rico (PR) AIDS Surveillance System was analyzed. From July 1981 through June 30 1995, a cumulative total of 15,877 AIDS cases have been reported in PR, 9,838 (62%) of these cases were reported in the San Juan SMSA and 2,044 (20.8%) were women. The male to female ratio was 3.8. The predominant mode of exposure among women was heterosexual contact (48.7%), followed by intravenous drug use (40.4%). The most affected age group among women was 30 to 39 years (43.3%) followed by 20-29 (26.2%). Eighty-one percent of women were in childbearing age. A substantial increase in AIDS cases has been reported for women who revealed heterosexual contact (from 45% in 1993 to 64% in 1995), representing the fastest growing category of AIDS cases in the island. The median survival time after reporting was 16.4 months (95% CI: 15.3-17.7) for males and 22.7 months (95% CI: 19.9 and 26.9) for females. Preventive efforts must be oriented toward education and risk behavior modification primarily directed to young women.

Treatment of bulimia with fenfluramine and desipramine.

Desipramine and fenfluramine were administered to bulimic patients in a 15-week study of double-blind, placebo-controlled, crossover design. The 22 patients in the study met DSM-III criteria for bulimia and were of normal weight. Twelve subjects were randomly allocated to the fenfluramine group, and 10 subjects received desipramine. Half the subjects in each group received the active drug in the first 6 weeks and half received placebo. There was a 3-week washout period, after which subjects were crossed over for the remaining 6 weeks. The Eating Disorder Inventory, profile of Mood States, bulimia symptom checklists, and Hopkins Symptom Checklist were administered at weeks 0, 2, 4, 6, 9, 11, 13, and 15. Subjects maintained a daily record of bingeing, vomiting, and laxative/diuretic abuse. Results indicated that both drugs had beneficial effects on bingeing and vomiting frequency, although a greater proportion of patients were identified who responded to fenfluramine than to desipramine. Fenfluramine and desipramine were also effective in reducing the psychological symptoms of bulimia, such as the urge to binge, and feelings of depression. Results suggest that direct alteration of central food intake regulatory centers can effectively control bulimia.

Computerized administration of the Diagnostic Interview Schedule.

The National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS) is a highly structured interview designed to be administered by lay interviewers and to yield psychiatric diagnoses. While the DIS has been used widely in large research centers, its use has been limited due to its complexity and need for extensive training to administer. In the present study 100 volunteers consisting of 80 psychiatric patients and 20 normal controls completed a self-administering computerized version of the DIS on two occasions. A standardized Computer Attitude Scale (CAS) was administered to each volunteer before the first and after the second computerized DIS (C-DIS). The C-DIS yielded acceptable test-retest reliability. Certain diagnoses were found to yield high test-retest reliability while reliability was lower for others. This general pattern was similar to the results of previous procedural validity studies. Patients found the C-DIS generally easy to use and operate, and after using the C-DIS, felt that their level of expertise in using computers had improved. Generally, the results support the use of computerized administration of the DIS.

The dexamethasone suppression test in bulimia: nonsuppression associated with depression and suboptimal weight.

This study was designed to assess the extent to which DST nonsuppression in bulimic women could be predicted by the incidence of major depression in the patient and her family and by other factors known to affect DST results, such as suboptimal weight. The DST was administered to 33 women who met DSM-III criteria for bulimia. Subjects were given a complete psychiatric and psychological assessment, including the National Institute of Mental Health Diagnostic Interview Schedule, a personal and family medical history questionnaire, the Hopkins SCL-90, and the Eating Disorders Inventory. Ideal weight was determined with Metropolitan Life tables. The rate of DST nonsuppression was 58%. Nonsuppression was more frequent among women who suffered from major depression and those who maintained a suboptimal weight. Depression and suboptimal weight were unrelated and thus appear to contribute independently to the high rate of DST abnormalities commonly seen in bulimia.

Utilization review of psychiatric day hospitals in a Canadian urban region; II. Utilization patterns.

This article reports on a study which reviewed the utilization of six adult psychiatric day hospitals in a Canadian urban region. Part II of the study looks at the utilization patterns of these services through the examination of patients' demographics and clinical characteristics. The application of the study results to the planning of psychiatric services in the region is discussed.

Utilization review of psychiatric day hospitals in a Canadian urban region. I. The service profile.

This article reports on a study which reviewed the utilization of six adult psychiatric day hospitals in a Canadian urban region. The study looks at the utilization of services through the examination of clinical service staffing patterns, accessibility, and gaps in service. It is hoped that this comprehensive overview will promote the establishment of standards and guidelines for psychiatric day-hospital services and further enhance the overall planning for psychiatric services in the region.

The need for aftercare services in a Canadian urban region: day-hospital patients' perspectives.

Day hospitals serve an important function in the rehabilitation of psychiatric patients. Community aftercare services are especially important to patients in this type of care. In order to determine the aftercare needs of day-hospital psychiatric patients in the Ottawa-Carleton region, a survey was conducted. A semistructured interview with a standardized questionnaire was administered by trained interviewers. Questions were asked regarding service use, problems encountered, and patient satisfaction. Information on housing, educational-vocational, financial, social-recreational, and medical services was gathered. The application of the study results to the planning of community psychiatric aftercare services for day-hospital patients is discussed.

Psychiatric emergency consultations to elderly patients in a Canadian general hospital.

The authors compared the demographic and clinical characteristics and treatment recommendations for elderly (greater than or equal to 60 years) and younger patients (17 to 59 years) seen for an emergency psychiatric consultation in a teaching general hospital. Findings revealed 11 distinctive characteristics that differentiated elderly from younger patients. Most notably, the elderly experienced their chief complaint for a longer time before referral to the emergency room by their primary care physician and had higher prevalence of affective disorders and psychologic factors affecting physical condition. Some of the implications of these results are discussed with the view to planning psychiatric services for the elderly and education programs.

The impact of a geriatric assessment unit on a psychiatric consultation service in a general hospital.

The opening of a geriatric assessment unit (GAU) in a large general hospital has affected the number of elderly patients referred for psychiatric consultation, the type of psychopathology seen, and the training provided for psychiatric residents and interns on the consultation-liaison service. To examine these changes, the six months prior to the opening of the GAU are compared to the six months immediately following its opening. The number of patients age 65 or older referred and diagnoses made by the consulting psychiatrists were studied. The opening of the GAU significantly increased the number of elderly patients referred for psychiatric consultation. It was found that the GAU offered unique advantages in the assessment and treatment of elderly patients with certain psychiatric problems, and the advantages and limitations of different facilities within the general hospital for the psychiatric assessment and treatment of elderly patients are discussed. A case is presented which illustrates the interplay between the consultation-liaison psychiatrist and the geriatric service in the management of an elderly patient referred for consultation. The experience of this hospital in providing psychogeriatric training for residents and interns on the psychiatric consultation service is reviewed.

Psychiatric consultation to elderly medical and surgical inpatients in a general hospital.

The elderly (65 years or older) constitute approximately 25% of the patients referred for psychiatric consultations in general hospitals. The authors compared the clinical characteristics of and treatment recommendations for elderly and younger (less than 65 years) patients. Our findings revealed fourteen distinctive characteristics which differentiated the elderly from the younger patients. Most notably, the elderly have had a longer hospitalization at the time of the request for a psychiatric consultation and had a higher prevalence of organic brain syndromes (O.B.S.). Some of the implications of these results are discussed with the view to planning psychiatric services for the elderly in general hospitals.

The teaching of psychotherapy in Canadian psychiatric residency programs: residents' perceptions.

In order to determine the residents' perceptions toward their psychotherapy training, a questionnaire was distributed to 400 residents in the 16 Canadian psychiatric residency programs. The main areas studied were: the resident's demographic and educational characteristics; the residency program characteristics; the type of training available in different psychotherapeutic modalities; the analysis of quality and quantity of attention given to different elements of psychotherapy supervision (patient assessment, diagnostic formulation of treatment approach and goals); the degree of importance attributed by the residents to the above mentioned elements of psychotherapy supervision; and the residents' perception of their supervisor's attributes (examples: teaching ability and rapport). Forty-two percent of the residents completed the questionnaire. Residents mentioned that the most adequate supervision was for long-term individual psychotherapy cases and that behavioral and group therapy supervision was the least adequate. The three most essential qualities in a supervisor's profile were judged to be: capacity for the development of a good rapport with the trainee; ability to pinpoint residents' psychotherapy shortcomings and his willingness to help residents to overcome them; ability to teach. Three factors that significantly influenced the trainees perception of their psychotherapy training were: resident's age, a seminar in individual psychotherapy in the residency core program; having received more than one hour weekly of psychotherapy supervision. The understanding of patient's psychodynamics was the most adequately taught element during psychotherapy supervision.

Utilization pattern of a Canadian psychiatric consultation service.

The authors reviewed 255 psychiatric consultations in a Canadian teaching general hospital over a one-year period. The majority of the patients were referred from the medical and surgical services. The three most commonly stated reasons for referral were either parasuicidal behavior, depression, or psychological conflicts affecting physical illness. The three most common primary psychiatric diagnoses were: affective disorders, organic brain syndromes, and transient situational disturbances. The factors influencing compliance among the patients referred for psychiatric ambulatory treatment were studied. Compliance was defined as attendance at the first appointment. Of the 42.8% of the patients referred for ambulatory psychiatric treatment, 54% complied.