Homelessness is a social condition increasing in frequency and severity across Canada. Interventions to end and prevent homelessness include effective case management in addition to an affordable housing provision. Little standardization exists for service providers to guide their decision making in developing and maintaining effective case management programs. The purpose of this 2-part article is to articulate dimensions of promising practice for case managers working in a "Housing First" context. Part 1 discusses research processes and findings and part-2 articulates the 6 Dimensions of Quality.
Practice settings include community-based organizations that employ and support case managers whose primary role is moving people from homelessness into permanent housing.
Six dimensions of promising practice are critically important to reducing barriers, improving sector collaboration, and ensuring case managers have appropriate and effective training and support. Dimensions of promising practice are: (1) collaboration and cooperation-a true team approach; (2) right matching of services-person-centered; (3) contextual case management-culture and flexibility; (4) the right kind of engagement-relationships and advocacy; (5) coordinated and well managed system-ethics and communication; and (6) evaluation for success-support and training.
Effective, coordinated case management, in addition to permanent affordable housing has the potential to reduce a person or family's homelessness permanently. Organizations and professionals working in this context have the opportunity to improve processes, reduce burnout, collaborate and standardize, and most importantly, efficiently and permanently end someone's homelessness with the help of dimensions of quality for case management.
To collect national baseline information on asthma management practices by physicians, and to compare these practices with the recommendations of the Canadian Asthma Consensus Conference ('the guidelines').
Cross-sectional survey of representative samples of physicians in Canada in late 1996 and early 1997.
Five specialty types of physicians who manage asthma patients: respirology, pediatrics, internal medicine, allergy and clinical immunology, and general practice and family medicine. Stratified sampling by province and specialty was used to select physicians for the study. Weighting was used in the analysis to generalize the results to the national level for the five specialty groups of physicians.
Mailed questionnaire, self-administered by the respondent; three mailings of the questionnaires were used to increase the response rate.
The frequency with which each of the five specialty types chose specific asthma management choices was determined, using weighted percentages representative of the specialty groups on a national basis. ANOVA determined the statistically significant differences among the five specialties in choosing particular asthma management actions. Then, logistic regression was used to calculate the odds ratios showing an association between the characteristics of the physician respondents and specific asthma management choices that they made in the survey.
The data analysis demonstrated significant variations among physicians in asthma management practices, according to specialty type and other characteristics. The initial report was released in April 1998, and manuscripts for journal submissions are being prepared.
We aimed to use the consensus opinion of a group of expert emergency physicians to derive a set of emergency diagnoses for acute abdominal pain that might be used as clinically significant outcomes for future research.
We conducted a cross-sectional survey of a convenience sample of emergency physicians with expertise in abdominal pain. These experts were authors of textbook chapters, peer-reviewed original research with a focus on abdominal pain or widely published clinical guidelines. Respondents were asked to categorize 50 possible diagnoses of acute abdominal pain into 1 of 3 categories: 1) unacceptable not to diagnose on the first emergency department (ED) visit; 2) although optimal to diagnose on first visit, failure to diagnose would not be expected to have serious adverse consequences provided the patient had follow-up within the next 2-7 days; 3) if not diagnosed during the first visit, unlikely to cause long-term risk to the patient provided the patient had follow-up within the next 1-2 months. Standard descriptive statistical analysis was used to summarize survey data.
Thirty emergency physicians completed the survey. Of 50 total diagnoses, 16 were categorized as "unacceptable not to diagnose in the ED" with greater than 85% agreement, and 12 were categorized as "acceptable not to diagnose in the ED" with greater than 85% agreement.
Our study identifies a set of abdominal pain conditions considered by expert emergency physicians to be clinically important to diagnose during the initial ED visit. These diseases may be used as "clinically significant" outcomes for future research on abdominal pain.
Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey.
BACKGROUND: Although primary care is the major target of coronary heart disease (CHD) clinical recommendations, little is known of how community physicians view guidelines and their implementation. The REACT survey was designed to assess the views, and perceived implementation, of CHD and lipid treatment guidelines among primary care physicians. METHODS: Semi-structured validated telephone interviews were conducted, in the relevant native tongue, with 754 randomly selected primary care physicians (GPs and family doctors) in five European countries (France, Germany, Italy, Sweden and the UK). RESULTS: Most physicians (89%) agreed with the content of current guidelines and reported use of them (81%). However, only 18% of physicians believed that guidelines were being implemented to a major extent. Key barriers to greater implementation of guidelines were seen as lack of time (38% of all physicians), prescription costs (30%), and patient compliance (17%). Suggestions for ways to improve implementation centred on more education, both for physicians themselves (29%) and patients (25%); promoting, publicizing or increasing guideline availability (23%); simplifying the guidelines (17%); and making them clearer (12%). Physicians perceived diabetes to be the most important risk factor for CHD, followed by hypertension and raised LDL-C. Most physicians (92%) believe their patients do associate high cholesterol levels with CHD. After establishing that a patient is 'at risk' of CHD, physicians reported spending an average of 16.5 minutes discussing risk factors and lifestyle changes or treatment that is required. Factors preventing this included insufficient time (42%), having too many other patients to see (27%) and feeling that patients did not listen or understand anyway (21%). CONCLUSIONS: Primary care physicians need more information and support on the implementation of CHD and cholesterol guideline recommendations. This need is recognized by clinicians.
Acupuncture is the complementary treatment most commonly used by general practitioners. This study describes the use of acupuncture among Norwegian general practitioners trained in acupuncture.
By telephone or mail, a questionnaire was presented to 212 general practitioners who had completed training in complementary acupuncture. They were asked to describe the use and effect of acupuncture and their attitude towards acupuncture.
Of the 111 physicians who replied (53%), 67 (60%) used acupuncture in their clinical practice. 78% had acupuncture courses of less than four weeks' duration only. 52% stated that acupuncture was the preferred treatment in more than 5% of their patients. About 70-80% used acupuncture as a supplement to conventional treatment. Acupuncture was commonly used in patients with musculoskeletal pain (93%), migraine (66%), and headache (63%), less often in patients with nausea, allergy, anxiety, sleep disturbances and gastrointestinal disorders. Improvement was reported in approximately three out of four patients. Lack of time was regarded as the major limitation to the use of acupuncture.
Many general practitioners trained in complementary acupuncture use acupuncture as an integrated part of their clinical practice.
Patients with head injury constitute a large population treated in primary health care. It is essential to recognize patients with traumatic brain injury among this notable population to determine the need for more specific evaluation. General practitioners (n=331) in Pirkanmaa hospital district in Finland received an email link to answer the survey. The response rate was 54.1% (n=179). Mean survey score was 20.5 points (max. 25). Only acquaintance with the national traumatic brain injury practice guidelines was associated with greater survey scores. The general practitioners' level of knowledge in managing head injuries was good. Deficiencies were found in the questions dealt with post-traumatic amnesia and the definition of traumatic brain injury.
The idea behind this thesis is to present how ARS and especially acute maxillary sinusitis in adults is diagnosed and treated in general practice. The study extends over many years, beginning with the first survey in 1991. Based on doctors' answers, we then investigated the diagnostic values ??of the symptoms, signs and examinations which the doctors reported using. All patients over 18 years suspected of acute maxillary sinusitis were included consecutively and only once and, after a clinical examination with the GP, they were offered the opportunity to enter into the prospective study referred to acute CT scan and by changes in the CT, immediately referred to sinus puncture. Both examinations were conducted at Aalborg Hospital. The disease was found most frequently in younger and 2/3 were women. The reason for this gender difference is unknown. We have assessed the diagnostic values of the symptoms, objective findings and investigations ??using 3 different reference standards: sinus puncture, microbiological diagnosis and CT scan described in three articles. In all examinations, it appeared that the usual signs and symptoms of acute maxillary sinusitis occur almost equally often and with a few exceptions in patients, with and without pus in the sinus cavities. Pain in the sinus cavities occurring in 95% of patients, and only elevated levels of CRP and ESR are significantly and independently associated with pus in the sinus cavities. This finding is surprising, because they are two nonspecific markers. CRP tested by near-patient testing has, within the investigations period, been introduced in general practice, and from 1999 the doctors also get reimbursed for performing the test. We have on this background originally defined a clinical criterion with pain over the sinuses accompanied by elevated values ??of CRP and/or ESR giving a sensitivity of 0.82, specificity 0.57, ppv 0.68 and npv 0.74. But looking at the ROC curve we suggest that a more clinical relevant diagnose will be based on use of CRP alone, as the test can be made easily and fast while the patient is in the clinic compared to the use of ESR. The disease is over-diagnosed in general practice. In only 53% of patients, who the GP suspected of having acute sinusitis, was there detected pus or mucopus at the sinus puncture, furthermore the patients' statements that they had had sinusitis was significantly negatively associated with current acute maxillary sinusitis. Almost all patients are prescribed topical treatment to the nose in the form of vasoconstrictor, and 50-70% also antibiotics. The most common bacteria that can be isolated are S. pneumoniae and H. influenzae. For many years the first drug of choice has been penicillin V, and treatment with penicillin V has followed Scandinavian recommendations. However, the resistance patterns in respect of H. influenzae have changed over the years and if the dominant flora is H. influenzae, then oral penicillin is not sufficient anymore, and should be replaced by amoxicillin with or without clavulanate. It is reported that the MIC of penicillin V is too high, such that oral dosage cannot provide sufficiently high concentrations. However, in daily clinical practice the doctor does not have the possibility to decide whether the infection is caused by either S. pneumoniae or H. influenzae, unless a sinus puncture is performed and it is not considered as a standard procedure. The recommended treatment is therefore starting with penicillin V, and at treatment failure switching to amoxicillin with or without clavulanate. It is well known that URTI's can exacerbate a chronic pulmonary disease - like asthma - in allergic patients, but this influence is also demonstrated as described in article 6 where ARS in adults without any sign of chronic lung disease or allergy is accompanied by a temporary reduction lung function. Future research should focus on the use of CRP in general practice, analysing cost-effectiveness of the use of CRP patient outcome in relation to antibiotic treatment, clarification of ARS as a female disease, and a detailed exploration of the relationship between URTI's and impaired lung function in lung-healthy patients.
Therapy for management of acute myocardial infarction (AMI) varies according to patient, prescriber and geographical characteristics.
To describe the in-hospital use of reperfusion therapy for ST elevation MI (STEMI) and discharge use of acetylsalicylic acid, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs) and statins in patients presenting with either STEMI or non-STEMI in Canada from 1999 to 2002.
Four Canadian registries (FASTRAK II, Canadian Acute Coronary Syndromes, Enhanced Feedback for Effective Cardiac Treatment and Improving Cardiovascular Outcomes in Nova Scotia) were used to identify patients with AMI in Canada and to measure in-hospital reperfusion and medication use. Use rates were compared by age, sex, time period and geographical area, according to available data.
Use rates for reperfusion in STEMI patients ranged from 60% to 70%, primarily representing fibrinolytic therapy. A delay in presentation to hospital after symptom onset represented an impediment to timely therapy, which was particularly pronounced for women and elderly patients. Overall, less than 50% of patients met the door-to-needle target of less than 30 min. Medication use rates at discharge increased from 1999/2000 to 2000/2001 across the different data sources: acetylsalicylic acid, 83% to 88%; beta-blockers, 74% to 89%; ACEIs, 54% to 67%; statins, 41% to 53%; and calcium antagonists, 21% to 32%.
Canadian and provincial rates of use of evidence-based medications for the treatment of AMI have increased over time, although there remains room for improvement. A single, comprehensive data source would supply better insights into the management of AMI in Canada.
AIMS: We performed an observational multicentre study to obtain information of the diagnostic tools and treatments currently used in patients with chronic heart failure (CHF) in primary health care (PHC) in Sweden. Data were collected from 2093 patients in 158 randomly selected PHC centres. METHODS AND RESULTS: The mean age was 79 years. The dominating aetiology of HF was hypertension and/or ischaemic heart disease. Diagnosis was based on symptoms and/or ECG and/or chest X-ray in 69% of the patients. Treatment with a renin-angiotensin system (RAS) blocker was ongoing in 74% of the patients, but only 37% had > or = 50% of the recommended target dose. In 68%, treatment with a beta-blocker (BB) was present, but only 31% had > or = 50% of the recommended target dose. Only 42% of the patients were on treatment with an RAS blocker and a BB and only 20% had > or = 50% of the recommended target dose. CONCLUSION: The diagnostic criteria for CHF according to the European Society of Cardiology were fulfilled in only approximately 30% of the patients. In addition, evidenced-based treatments to reduce morbidity and mortality were markedly underused, particularly regarding dosing. Our findings may reflect the patients' high age and the presence of important co-morbidities.
To investigate the adequacy of pharmacotherapy received by psychiatric inpatients and outpatients with a research diagnosis of bipolar I or II disorder, including patients both with and without a clinical diagnosis of bipolar disorder.
In the Jorvi Bipolar Study (JoBS), 1630 psychiatric inpatients and outpatients in 3 Finnish cities were systematically screened between January 1, 2002, and February 28, 2003, for bipolar I and II disorders using the Mood Disorder Questionnaire. By using SCID-I and -II interviews, 191 patients were diagnosed with bipolar disorder (90 bipolar I and 101 bipolar II). Information was collected on clinical history, diagnosis, and treatment. The adequacy of treatment received was evaluated.
Of the 162 patients with previous bipolar disorder episodes, only 34 (20.9%) of all and 30 (55.5%) of those with a clinical diagnosis of bipolar disorder were using a mood stabilizer at onset of the index episode. Only 81 (42.4%) of all 191 patients and 76 (65.0%) of those diagnosed with bipolar disorder received adequate treatment for the acute index phase. The factor most strongly independently associated with adequate treatment was clinical diagnosis of bipolar disorder (OR = 25.34). In addition, rapid cycling (OR = 2.45), polyphasic index episode (OR = 2.41), or depressive index phase (OR = 3.36) independently predicted inadequate treatment. Outpatients received adequate treatment markedly less often than inpatients.
Clinical diagnosis of bipolar disorder is by far the most important prerequisite for adequate treatment. Problems in treatment are associated mostly with outpatient settings, where adequacy of treatment of bipolar depression is a major concern. Lack of attention to the longitudinal course of illness is another major problem area.