Can a health advocate for homeless families reduce workload for the primary healthcare team? A controlled trial.

The objective of the present study was to determine whether provision of health advocacy for homeless patients would reduce the burden of care for a primary healthcare team. The impact of a health advocacy intervention was assessed in a quasi-experimental, three-armed controlled trial. Homeless patients registering at an inner-city health centre were allocated in alternating periods to health advocacy (with or without outreach registration) or 'usual care' over a total intake period of 3 years. The client group were homeless people in hostels or other temporary accommodation in the Liverpool 8 area of the UK. The majority of participants (n = 400) were women (76%) in their twenties (mean age = 26.6 years). Most (63%) were temporarily housed at either one of the women's refuges or Liverpool City Council family hostels, and all were registered with an inner-city health centre. Data on health service utilisation over a 3-month period was collected for all clients recruited to the study and direct health service costs were measured. Homeless adults who were proactively registered by the health advocate on outreach visits to hostels made significantly less use of health centre resources whilst having more contact with the health advocate than patients who registered at the health centre at a time of need. There was no reduction in health centre workload when the offer of health advocacy was made after registration at the health centre. The additional costs of providing health advocacy were offset by a reduction in demand for health-centre-based care. The results demonstrate that health advocacy can alter the pattern of help-seeking by temporarily homeless adults. The intervention was cost-neutral. The short-term health service workload associated with symptomatic homeless patients requiring medication was not reduced, but outreach health advocacy was used successfully to address psycho-social issues and reduce the workload for primary care staff.

Tackling the needs of the homeless: a controlled trial of health advocacy.

The objective of the present study was to assess the effectiveness of a health advocate's casework with homeless people in a primary care setting in terms of improvements in health-related quality of life (QoL). The impact of the health advocacy intervention was assessed in a quasi-experimental, three-armed controlled trial. Homeless people moving into hostels or other temporary accommodation in the Liverpool 8 area of the UK and patients registering at an inner-city health centre as temporary residents were allocated in alternating periods to health advocacy (with or without outreach registration) or 'usual care' over a total intake period of 3 years. Health-related QoL outcomes were assessed using three independent self-report measures: the Life Fulfilment Scale; the Delighted-Terrible Faces Scale; and the Nottingham Health Profile. Out of the 326 homeless people who were given baseline questionnaires at registration, 222 (68%) returned usable questionnaires. Out of these individuals, 171 (77.0%) were traceable at follow-up, and 117 (68.4%) follow-up questionnaires were returned. The majority of respondents (n = 117) were women (72%) who were under 30 years of age (74%), white British (91%), and single (63%) or separated (23%), many of whom were living with their children (41%) in either women's refuges (30%) or family hostels (25%). Improvements in health-related QoL were greatest in people recruited and supported by a health advocate early in their stay in temporary housing, in comparison with those in the control group given 'usual care' at the health centre. The model of streamlined care for patients with complex psycho-social needs is shown to be a worthwhile and effective option for primary healthcare providers.

Uptake and costs of care for epilepsy: findings from a U.K. regional study.

PURPOSE: Epilepsy is a common neurological condition, with significant resource implications for the health services, but few studies to date have examined the uptake and costs of care for this condition. As part of a large prevalence study of epilepsy conducted in one U.K. Health Region, we investigated both direct and indirect costs of epilepsy care and measured and valued the direct costs. METHODS: Data about service use were obtained from primary physician records and patient questionnaires. Unit costs for each item of resource use were generated from several sources. RESULTS: The greatest direct health care cost is that of hospital-based care. Pharmaceutical services also represent a significant element of the cost of epilepsy, the financial costs of prescribing newly developed antiepileptic drugs (AEDs) being large relative to those of the older drugs; therefore, the benefits derived from their use must be carefully assessed. The importance of good seizure control is amply illustrated by the findings about the differential costs associated with epilepsy of varying severity. The direct costs of caring for people with poorly controlled epilepsy are significant, with more than half the total cost of epilepsy care accounted for by patients with frequent seizures even though this group represented only a quarter of all patients in the present study. CONCLUSIONS: Our data emphasize the importance of optimizing seizure control as a means of reducing the costs of epilepsy, not only to the person with the condition, but also to society.

A general practice records audit of the process of care for people with epilepsy.

BACKGROUND: The appropriateness of epilepsy as a topic for general practice audit activity has been emphasized, but few audits have been undertaken to data and those that have are small scale. Historically, management of epilepsy has been a neglected area, and services for people with epilepsy remain generally poor. AIM: The study was designed to examine the process of care for people with epilepsy through a region-wide audit of general practitioner records. METHOD: General practitioners in 31 randomly selected general practices in one UK health region undertook a notes audit for all patients identified as having active epilepsy (patients who had had seizures in the last 2 years, or were currently seizure-free but on antiepileptic medication). A standard pro forma was used to collect information relating to diagnosis, drug treatment, and primary and secondary care contacts. RESULTS: Recording of information in the notes was generally good, but poor for some key items essential to the effective management of the condition; results suggest that a number of recommendations about provision of care for epilepsy are not being met: in particular, EEG and CT investigations often appear poorly directed; prescribed antiepileptic therapy is not always optimal; significant numbers of patients are being treated in hospital by non-neurologists; there is little evidence of any regular review being undertaken by general practitioners of their patients with epilepsy; and counselling about the non-clinical aspects of epilepsy often appears inadequate. CONCLUSIONS: Despite recommendations in a number of recent reports, gaps and inconsistencies in epilepsy care persist, both at the primary and secondary level. The means by which such shortcomings can be reduced (e.g. by specialist epilepsy nurses working across the primary-secondary care interface) should now be systematically examined. The study has highlighted a need for evidence-based guidelines which span the primary-secondary care interface and clarify the contribution of the various practitioners involved in the provision of care for people with epilepsy.

Patients' experiences of and satisfaction with care for their epilepsy.

PURPOSE: To determine condition-specific satisfaction with care, we studied patients' experience of general practitioner (primary physician) and hospital clinic care for their epilepsy and their views about the provision of information concerning the management of their condition. METHODS: A postal questionnaire was sent to an unselected, community-based population of patients with epilepsy. In addition to clinical and demographic details and previously validated scales of psychosocial well-being, the instrument contained a series of questions about patients' experiences and views of the care they received for epilepsy from both general practice and the hospital services. RESULTS: Doctors' interpersonal skills were the most influential factors affecting both patient satisfaction overall and the likelihood that doctors might discuss with patients certain clinical and social issues surrounding the management of the patient's condition. A sizable proportion of patients reported that they received insufficient information about epilepsy, both from hospital doctors and general practitioners. CONCLUSIONS: Patients with epilepsy place great importance on having a doctor who is approachable, communicative, and knowledgeable and on receiving adequate information about their condition. Clinicians may need to be made more aware of the importance of accessibility and sensitivity to the nonclinical needs of their patients. Such easily implemented changes in the delivery of care would improve services in the United Kingdom for people with epilepsy.

Mental health in the community.

Medical education needs to reflect the rapid development of community-based health care, particularly in the area of mental health. 'Mental health in the community' is a week-long collaborative course organized through the Department of General Practice at Liverpool University for first-year clinical medical students. It aims to introduce them to the range of mental health problems that exists in the community and the resources available to deal with them; to improve their counselling skills and to reduce their anxiety about mental health, both their own and other people's. The paper describes the wide variety of teaching methods and visits which are offered during the week. The course is evaluated using the method developed by Stake. Although there are some problems with student participation, 'Mental health in the community' has a significant positive overall effect on students' knowledge and anxiety levels with regard to mental health. It is making a contribution to the reorientation of medical education in Liverpool.

Low-frequency septal stimulation increases tyrosine hydroxylase activity in the hippocampus.

Rats were chronically implanted with recording electrodes in the dorsomedial subiculum and stimulating electrodes in the septal area. Low-frequency septal stimulation (regular inter-pulse interval = 130 msec) was used over a period of 10 days to drive the hippocampal theta rhythm at 7.7 Hz (a régime shown previously to proactively facilitate acquisition of barpressing and retard its extinction), and high frequency (77 Hz) stimulation was used to block theta rhythm (a régime shown previously to proactively retard acquisition of barpressing and facilitate its extinction). The activity of soluble tyrosine hydroxylase from hippocampus increased in animals killed 15-33 days after the end of the period of 7.7 Hz septal stimulation but not after high-frequency stimulation. Irregular low-frequency stimulation with a mean inter-pulse of 130 msec produced the same effect on tyrosine hydroxylase activity as regular 7.7 Hz theta-driving. The possible relations between the effects of low-frequency septal stimulation on hippocampal tyrosine hydroxylase and on behavior are discussed.

The effects of footshock and handling on tyrosine hydroxylase activity in synaptosomes and solubilised preparations from rat brain.

The effects of mild noxious stimulation on central noradrenergic activity were investigated in rats, using low-intensity electrical footshock as the noxious stimulus. Synaptosomes were prepared from brain regions of control and experimental rats and the rate of tyrosine hydroxylation was assayed: this is a measure of transmitter synthesis in the isolated noradrenergic terminals. Single footshocks were found to elevate the synthesis rate in the hippocampus, the extent of the elevation depending on the baseline rate. This elevation was not significant in hypothalamus or cerebellum. Repeated handling over a period of 14 days was also found to elevate synthesis rate in hippocampus; but rats subjected to daily footshock for a week, in addition to handling, had synthesis rates similar to those of controls. Maximal tyrosine hydroxylase activity was measured by solubilizing the enzyme and assaying at saturating concentrations of cofactor and substrate: this is a measure of the amount of enzyme in the nerve terminals. No significant changes in maximal tyrosine hydroxylase activity were found in the brains of handled or shocked animals. These results suggest that the assay of tyrosine hydroxylase activity in a suspension of synaptosomes provides a sensitive indicator of changes in noradrenergic activity related to mild noxious stimulation. The biochemical responses are more pronounced in the hippocampus than in other noradrenergic terminal areas; this suggests that the synthesis rate of noradrenaline in terminals of central noradrenergic neurones could be regulated by local mechanisms at the terminal as well as by impulses transmitted from the cell body.