Managing patient discharge to home: the challenges of achieving quality of care.

Discharging older patients from hospital to care at home presents considerable challenges for those concerned about the current mandate of quality management. A great many professionals with different priorities and organizational commitments are involved. The policies and procedures of at least two agencies, a hospital and a home care agency, play a role in shaping the whole process. The purpose of this study was to explore and describe factors other than medical condition and treatment which shaped the quality of the discharge experiences of older patients. Qualitative research methodology was used to document the discharge process from the perspective of 12 rural and nine urban patients, and a purposeful sample of 22 family caregivers and 117 professionals involved in their care. As well, 24 agency administrators with an overview of related policies and procedures provided data. Findings provide an in-depth description of the different implementation approaches and related quality issues in rural and urban settings. Quality management was undermined by role confusion, compromised and overly zealous pursuit of efficiency, fragmented work, variable physician practice style, and communication and coordination problems. Several readily implemented solutions to these problems are recommended. The implications of the more difficult leadership challenges related to achieving reasonable efficiency and maintaining a humane orientation in the complex care system are addressed.

Hearing loss in elderly patients in a family practice.

OBJECTIVE: To investigate hearing loss in elderly patients. DESIGN: Cohort study. SETTING: Family practice. PATIENTS: All ambulatory patients 65 years of age or older who attended the practice from June to August 1989. OUTCOME MEASURES: The Hearing Handicap Inventory for the Elderly--Screening Version (HHIE-S) and the Welch-Allyn Audioscope. Patients who failed one or both of the screening tests were referred to a speech and hearing clinic for audiologic assessment and treatment recommendations. Those with hearing aids were excluded from the main study but were given the opportunity to have them assessed at the clinic. MAIN RESULTS: Of 157 eligible patients 42 were excluded: 16 refused to participate, 13 already had hearing aids, and 13 could not be contacted. Of the remaining 115, 34 failed one or both of the tests (14 failed the HHIE-S, 9 failed the audioscope test, and 11 failed both). Of the 34, 25 completed the audiologic assessment at the clinic. Fifteen were found to have severe hearing impairment; the recommendation was hearing aids for 12, further assessment for 2 and no treatment for 1. Of the remaining 10 patients it was thought that 6 would benefit from hearing aids. Ten of the 11 patients with hearing aids who agreed to undergo testing at the clinic were found to need an adjustment or replacement of their devices. CONCLUSIONS: Hearing loss is a significant problem in elderly patients in primary practice. Further study is required to determine which of the two screening tools is most effective. Most elderly patients with hearing aids may require modification or replacement of their devices.

Evaluating A Graduate Studies Program: A survey of former participants.

To evaluate the outcome of the program for graduate studies in family medicine at the University of Western Ontario, all 45 participants in the program were surveyed. Thirty-six percent of respondents held full-time academic appointments and 42% part-time academic positions. Eighty-four percent indicated a moderate to major effect on their career as a teacher; 67% indicated a moderate to major change in research skills; 42% indicated such a change in administrative skills. Ninety-one percent said they had achieved all or most of their objective in taking the program.

Influenza vaccination: a comparison of two outreach strategies.

Despite longstanding recommendations for annual influenza vaccination of all people age 65 and older, only 20% or less are regularly immunized. This paper compares two methods of immunization outreach to the elderly population. In 1985 and 1986 vaccine was offered to patients who attended one family practice for any reason during the months of October and November. In 1985 if patients had not received vaccine by October 31 an informational letter recommending immunization was also mailed. In 1986 nonimmunized patients were telephoned by the family practice nurse and informed of the rationale, availability, and advisability of receiving the vaccine. The immunization rate improved in patients attending the practice over the two study years. Additional outreach efforts showed a high degree of failure or refusal to receive immunization.

Factors determining patients' satisfaction in a family practice residency teaching center.

A primary function of family medicine teaching centers is to provide residents with ongoing experiences with patients and their families. A critical issue in maintaining a stable patient population for such teaching is patient satisfaction. In the study reported here, the authors examined the factors determining patients' satisfaction. A questionnaire was mailed to a representative sample of 10 percent of the patients in a family practice in a family medical center. Seventy-eight percent of the sample responded; these respondents were representative of the sample population. Four variables were identified as significant in determining the patients' satisfaction: whether the patients felt that the time spent with their identified family physician was adequate and that the physician's explanations regarding their health care and the teaching program were clear; whether the patients felt comfortable in expressing their concerns about the teaching program to the permanent staff members; whether the patients had a positive attitude regarding the teaching program; and whether the patients felt that their identified family physician was available to them.

Family physicians' perspective of patient care at the london regional cancer clinic.

This article describes a survey of the opinions of family physicians practising in the London, Ontario, area concerning the management of doctor/patient relationships and patient treatment in cases referred by family physicians to the London Regional Cancer Clinic. Findings clearly identified a need for better communication between Clinic staff and referring family physicians, greater continuity of care for patients at the clinic, continuing family physician support of patients during periods of hospitalization at the Clinic, and some administrative adjustments in Clinic routines that would reduce patient stress and discomfort and improve morale.

Acceptability of a faecal occult blood screening protocol for carcinoma of the colon in family practice.

Cancer of the colon is the second most common malignancy in North America and screening methods are needed for diagnosing the lesions at an early stage. Faecal occult blood screening is a method of secondary prevention which is particularly adaptable to the family practice setting. In order to test the feasibility of using this test in family practice, 16 family physicians participated in a trial screening programme using the Hemoccult II test. During the two-month trial 776 patients over 40 years of age were screened; 19 of the tests were positive but in two cases patients were thought to have failed to follow dietary and medical restrictions. Of the 17 patients with verified positive tests, further investigation showed five patients had neoplastic disease and three of these had malignant disease. The detection rate for cancer of the colon using the Hemoccult II test was therefore 3/776, equivalent to 3.9 per 1000 cases screened. By narrowing the age range for screening patients to between 45 and 75 years, the time involved to screen the population at risk could be decreased.

Are antihistamine-decongestants of value in the treatment of acute otitis media in children?

Acute otitis media is the most common bacterial infection of childhood. The effectiveness of oral antihistamine-decongestant mixtures in the treatment of this illness remains controversial in clinical practice. In a double-blind randomized study, 82 children (aged under 15 years) with acute otitis media were treated with amoxicillin and either a decongestant-antihistamine mixture (Dimetapp) or placebo. All diagnoses required agreement between a family practice resident and the supervising family physician. Clinical course was assessed by symptom diaries completed by parents and by follow-up examination at approximately two weeks, which included pneumatic otoscopy. No statistically significant benefit of the antihistamine-decongestant mixture was shown in terms of resolution of the symptoms or prevention of the complications of acute otitis media. It is recommended that antihistamine-decongestants not be routinely added to an antibiotic in the treatment of acute otitis media in children.

Pap smear practice patterns of family physicians.

London, Ontario family physicians were surveyed, to compare the frequency of their Pap smear screening and their management of the abnormal smear with the recommendations of the 1982 Task Force report on cervical cancer screening. Considerable variation was observed between the Task Force recommendations and frequency of screening 36-60-year-old women, and the management of mild, recurrent mild, and moderate dysplasia. Many family physicians appeared to rely heavily on the cytopathologist's recommendations. More uniformity is required, both in cytopathologists' recommendations and in the practice of family physicians, if cervical cancer screening programs are to achieve their maximum effectiveness.

Management of cervical dysplasia.

Since the 1982 Revised Task Force Report on Cervical Cancer Screening, controversy has developed over the management of mild dysplasia. Recent developments have led some investigators to recommend colposcopy for any degree of cervical dysplasia because of significant false-negative factors in Pap smear reporting and the observation that some patients have lesions more severe than suggested by the cytology. Over a four-year period, all patients with dysplastic smears in the practice were evaluated by colposcopic examination and biopsy. In 20 cases of mild dysplasia, five cases of cancer in situ were found. Considerable variation from the Task Force's report was noted in cytopathologists' recommendations for cytological smears. Judging from the results of this audit, colposcopic evaluation of all dysplastic smears should be considered.

Hemoccult II Screening for Bowel Cancer: Will Family Practice Patients Accept It?

Acceptability to patients of Hemoccult II® screening for bowel cancer will be a major determinant of whether such screening programs can be successfully implemented. In order to evaluate the screening test's acceptability to patients, compliance rates were assessed in 17 family practices in London, Ontario. Patients' reactions to the test were assessed by both a retrospective questionnaire and a similar prospective questionnaire. Respondents indicated the test's unpleasantness, dietary preparation, and forgetfulness were the most prominent factors associated with non-compliance. The concurrent use of other medications was also identified as a limiting factor. Knowledge of these factors may assist the family physician in improving patients' acceptance of the test.

The impact of an organized approach to prevention.

A study was conducted to compare preventive strategies in an urban, southwest Ontario family practice before and after the adoption of a periodic health assessment flow sheet. The flow sheet is similar to one developed by Frame and Carlson; the patient's history, screening procedures, health practices, and individual risk factors can be recorded on it. Approximately one hundred charts of patients between age 20 and 55 were randomly selected for the study. A comparison was made between the first general health assessment made from 1970-1977, before the flow sheet was used, and the first assessment from 1978-1982, when the sheet was used. There were significant differences between the assessments. Before 1978, a cholesterol test was requested for only 15.1% of patients in the study, immunization status was discussed with only 11.3%, and no record was made of their health practices. After 1978, cholesterol tests were requested for 82.2%, immunization status was discussed with 93.3%, and health practices were recorded for 82.2%. It is relatively easy to incorporate the flow sheet into practice, and it can be used to provide consistent preventive care.

Screening for carcinoma of the colon: a family practice perspective.

Carcinoma of the colon is the second commonest malignancy in both sexes in North America. With little hope for a suitable method of primary prevention, physicians are forced to look for an effective secondary preventive technique. Through a collaborative effort between the physician and family practice nurse, an effective protocol for screening was developed and implemented on 355 patients aged over 40. Of these, 17 were positive. Ten of those were true positive and seven false positive. One false negative was found, but no carcinoma has been found to date-the positive patients have polyps, diverticular disease or hemorrhoids. In view of increasing evidence for the polyp-cancer sequence, this finding may be significant. Widespread use of Hemoccult II in this fashion will clarify the usefulness of this test.

Ephedrine-induced cardiomyopathy.

A young woman presented with congestive cardiomyopathy of unknown aetiology. She subsequently revealed a history of longstanding abuse of ephedrine-containing preparations. The case is reported to alert clinicians to a hazard of dependence on proprietary pharmaceuticals.

The sportsman with hypertension.

The widespread use of antihypertensive therapy in a large number of active Australians has prompted a review of the effects of sporting activity on hypertension and its treatment.

Renal and cardiac complications of drug abuse.

The case is presented of a young man who, after prolonged intravenous narcotic administration, developed subacute bacterial endocarditis involving the aortic valve, and rapidly progressive glomerulonephritis. After treatment of and recovery from renal failure, persistent proteinuria was shown to be caused by focal glomerulosclerosis. The association of these lesions with "mainlining" is reviewed.