摘要:

In spite of technological advances in healthcare, poor maternal and infant birth outcomes remain at unacceptably high levels in Western countries. Therefore, governmental and healthcare institutions, particularly in North America, have implemented various models of expanded prenatal-care programs focused on improving birth outcomes of high-risk pregnant women. This article presents an overview of recent studies that evaluated the quality and cost (if available) of programs (case management, home care, nurse specialist care, or augmented prenatal care) for the management of high-risk pregnancy. The findings suggest that enhanced prenatal programs (particularly with expert nurses) improve birth outcomes while controlling costs. These enhanced programs provide early and continuing psychosocial assessment, psychosocial interventions to mediate the effects of the risk factors, and health promotion education.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Lower urinary tract symptoms are common in the male population over 50 years of age. While in the majority of patients there are no sinister underlying abnormalities, it is important that men are educated to present for investigation and management at an early stage. Shared care between hospital services and primary care has resulted in significant improvements in patient care over the last 10 years. Clarification about the terminology used and the risk factors for progression has led to more appropriate targeting of treatment to those men who will benefit most. Further research into the natural history of benign prostate and bladder conditions will yield further improvements.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Psychological morbidity after childbirth is a major public health problem, with prevalence rates of depression ranging from 10−15%, depending on assessment times and diagnostic criteria. Depression can have long-lasting consequences for both the woman and her child, with increasing evidence of an association between maternal depression and effects on the child's behavioral and cognitive development. A variety of interventions implemented during the antenatal, intrapartum and postnatal periods to reduce postnatal psychological morbidity have been evaluated. This paper summarizes the outcomes of studies that have evaluated interventions provided by midwives.There is no evidence to suggest that changing routine antenatal visit schedules will benefit postnatal psychological health or to support the introduction of routine antenatal screening to identify women more vulnerable to postnatal depression. Evaluation of the role of the midwife in implementing recommendations for screening women to identify those at risk of recurrence of serious mental illness during and after pregnancy is necessary. Educational interventions, including those specifically tailored for women deemed more vulnerable to depression, have shown limited evidence of benefit, and further research in this area is warranted. There is currently little evidence to support postnatal debriefing by midwives, with some evidence to suggest this intervention may actually be harmful to psychological well-being. The widespread introduction of debriefing services to postnatal women, particularly in the UK, highlights the urgent need for further research into the definition and content of this aspect of midwifery care. Significant benefits to postnatal psychological well-being have been found following the implementation of new models of midwifery-led care. Such findings have important implications for the role of the midwifery services within the UK, as well as for maternity service provision in other healthcare systems. Further evidence is required to inform how midwifery care can best be provided to all women throughout the maternity episode to ensure the early detection and management of postnatal psychological morbidity. Preventative and management strategies of postnatal psychological morbidity should consider the direct and indirect costs to women, healthcare providers and funders.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Depression is a common and important problem in the primary care setting. Despite the fact that effective treatments are available, the recognition, management and outcomes of depression in primary care are far from optimal. A variety of approaches to remedy these problems have been evaluated, including: physician education programs; depression screening and feedback; protocol-based treatment by mental health specialists in the primary care setting; and a variety of disease management strategies. Based on this work, we have learned that improving the care and outcomes of depression in primary care requires some or all of the following: a systematic approach to the recognition and assessment of depression; evidence-based decision support; patient education and activation; ongoing monitoring and feedback regarding patient adherence and outcomes; integration of mental health specialists for patients who are not improving as expected; and physician education. However, interventions that include these components have not been sustained or widely disseminated because of the time, energy, commitment and resources that are required. Successful interventions must be low cost, easy to implement, and they must meet the needs of all stakeholders (i.e. payors, providers, patients and behavioral healthcare companies). Innovative programs that take advantage of new technologies have been recently developed to address these challenges, but require further evaluation.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Several national and international organizations have developed and published guidelines for the treatment of patients with community-acquired pneumonia (CAP). Guidelines from Europe, the US, Canada and Latin America classify patients in different groups based on the severity of pneumonia, site of care and presence of risk factors for resistant organisms. The initial antibacterial therapy is designed to cover only the likely organisms able to infect a particular group of patients. An evaluation of current guidelines indicates that there are significant similarities in regard to classification of patients and initial antibacterial therapy. One objective of this review is to present the clinician with a practical approach to antibacterial selection based on current published guidelines for CAP.Although most of the care recommended in guidelines is evidence-based and associated with better clinical outcomes and/or decreased healthcare cost, there is still a significant gap between recommended care and actual care of patients with CAP. Dissemination of guidelines at the local level has proved to have a minimal effect in changing local practices. To bring the local care of patients with CAP closer to the care recommended in guidelines, it is necessary to have an appropriate plan for guideline implementation. This review provides the clinician and other healthcare decision-makers with a methodology for implementation of national guidelines at the local hospital level.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

IntroductionClinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. When adhered to, they have been shown to have the potential to improve both the process of care and patient health outcomes. Economic issues can be incorporated into guidelines with respect to both recommendations (based on the criteria of cost effectiveness) and defining outcomes for assessing adherence with guidelines.MethodsWe reviewed 217 Canadian clinical practice guidelines relating to prescription medications. The role of economics within existing practice guidelines was assessed using standardized abstracting techniques.ResultsCosts or economics were considered in only 26% of the guidelines identified. The role of economic considerations within these guidelines varied considerably from a relatively minor to major role. Furthermore, only 4% of guidelines defined measurable outcomes, including economic outcomes, that could be monitored to assess adherence with recommendations.ConclusionsThe inclusion of economic considerations in clinical guidelines in Canada is limited. The possible reasons for this lack of economic considerations need to be explored further. Without consideration of economic issues when developed, clinical practice guidelines may lead to a more inefficient healthcare system.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

摘要:

Objectiveto present the results of our 1-year, telephonic disease management interventions for 349 patients with mild to severe chronic obstructive pulmonary disease (COPD).Methodsparameters measuring utilization of medical services, days lost from work, and quality-of-life measurements (utilizing the St. George’s Questionnaire) were determined for the 12-month period prior to enrollment of patients and compared with those observed during the 12-month participation in the program.Resultsthere was a statistically significant reduction in all utilization measurements and a statistically significant improvement in quality of life. Emergency room (ER) visits decreased by 57% (p < 0.001), hospitalizations by 53% (p < 0.001), intensive care unit admissions by 66% (p = 0.001), unscheduled office visits by 67% (p < 0.001), and oral antibacterial bursts by 48% (p < 0.001). Of the 114 employed patients, days missed from work were reduced by 77% (p < 0.001). The total saving from reduction in hospitalizations and ER visits was $US672 000. This was against an approximate cost of the program of $US223 500 (average of $US635 per enrollee). Costs associated with medications and physician visits were not obtained.Conclusionsthese outcomes suggest that, with ongoing patient support, the provision of physical rehabilitation, and improved communication between those engaged in the healing process, it is possible to reduce utilization and overall healthcare expenditures and improve the quality of life for a population of patients with moderate to severe COPD. This intervention was both cost effective and medically effective. Our experience suggests that further trials of COPD disease management are warranted.

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS

ISSN:1173-8790    

出版商:ADIS    

年代:2003

数据来源: ADIS