Gastro-oesophageal reflux disease - Impact of guidelines on GP management

Copyright © 2008 Royal Australian College of General Practitioners Copyright to Australian Family Physician. Reproduced with permission. Permission to reproduce must be sought from the publisher, The Royal Australian College of General Practitioners.Background: This program examined the impact of clinical guidelines and a 3 year self audit process on general practitioners’ diagnosis and management of gastro-oesophageal reflux disease. Methods: Nine hundred and sixty-six Australian GPs participated in a retrospective five step clinical audit reporting on data for 28 622 patients. Results: General practitioners demonstrated significant improvements in their diagnosis and management of gastro-oesophageal reflux disease across the audit period, including: - a significant 3% decrease in use of endoscopy - improved GP assessment and identification of risk factors and exacerbants - significant increases in GP recommendations for patient weight loss and dietary change (7 and 10% respectively) - a significant 4% reduction in patient use of medications that may exacerbate reflux symptoms. Discussion: The findings provide a snapshot of current diagnostic and management practices in Australian general practice, and highlight the benefits of clinical audit as a tool for eliciting evidence based, guideline driven practice change.Catherine N Kirby, Leon Piterman, Mark R Nelson and John Den

Community attitudes to institutional care of the aged in Hong Kong

The objective of the study was to assess community attitudes to institutional care of the aged in Hong Kong. A random sample of 1,023 adult residents were telephone-interviewed. 22.7% and 57.5% of the respondents agreed or strongly agreed that non-disabled and disabled elderly be accommodated in institutions respectively. Social factors of the respondents and physical and behavioural factors of the elderly had significant effects on these attitudes. Furthermore, age, gender, educational level and experience in living or looking after elderly also had significant effects. This study provides important information on the community attitudes to institutionalization of the elderly in Hong Kong. These attitudes will have significant effects on the demand for institutional care for the elderly in the next decade. The findings should also help health care workers identify elderly at-risk of institutionalization. Hence, early intervention may help reduce some of these placements.published_or_final_versio

Help-seeking behaviours for psychological distress amongst Chinese patients

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An inclusive approach to raising standards in general practice: working with a 'community of practice' in Western Australia

<p>Abstract</p> <p>Background</p> <p>In this study we explored the challenges to establishing a community of practice (CoP) to address standards in general practice. We focused on the issue of improving referral letters which are the main form of communication between general practitioners (GPs) and specialists. There is evidence to suggest that the information relayed to specialists at the time of referral could be improved.</p> <p>Methods</p> <p>We aimed to develop a community of practice consisting of GPs in Western Australia to improve the quality of referral letters to six specialty clinics. Three phases included: establishing the CoP, monitoring the progress of the CoP and sustaining and managing the CoP. The CoP's activity centred on referral letters to each of six selected specialties. A local measure for the quality of the referral letters was developed from a survey of participants about specific items of history and weighted for their perceived importance in the referral letter. Referral letters by participants written before and after the benchmarking exercise were scored for quality based on the standards set by the CoP. Feedback to participants regarding the 'quality' of their individual referrals was provided by a nominated member of the CoP, including a comparison of before and after scores.</p> <p>Results</p> <p>15 GPs were recruited. Only five GPs submitted referral letters both before and after benchmarking. The five GPs that participated in both study phases submitted a total of 102 referral letters (53 before and 49 after). There was a 26 point (95% CI 11–41) improvement in the average scores of the second set of letters after taking clustering by speciality into account, indicating the quality of referral letters improved substantially after feedback.</p> <p>Conclusion</p> <p>There are many challenges to forming a CoP to focus on improving a specific issue in general practice. However we were able to demonstrate that those practitioners who participated in all aspects of the project substantially improved the quality of their referral letters. For recruitment it was important to work with a champion for the project from within the practice. The project took several months to complete therefore some GPs became disengaged. Some were very disappointed by their performance when compared to colleagues. This reaction may be an important motivation to change, however it needs to be sensitively handled if participants are not to become disillusioned or disheartened.</p

Synthesis from Recursive-Components Libraries

Synthesis is the automatic construction of a system from its specification. In classical synthesis algorithms it is always assumed that the system is "constructed from scratch" rather than composed from reusable components. This, of course, rarely happens in real life. In real life, almost every non-trivial commercial software system relies heavily on using libraries of reusable components. Furthermore, other contexts, such as web-service orchestration, can be modeled as synthesis of a system from a library of components. In 2009 we introduced LTL synthesis from libraries of reusable components. Here, we extend the work and study synthesis from component libraries with "call and return"' control flow structure. Such control-flow structure is very common in software systems. We define the problem of Nested-Words Temporal Logic (NWTL) synthesis from recursive component libraries, where NWTL is a specification formalism, richer than LTL, that is suitable for "call and return" computations. We solve the problem, providing a synthesis algorithm, and show the problem is 2EXPTIME-complete, as standard synthesis.Comment: In Proceedings GandALF 2011, arXiv:1106.081

Impact of a referral management “gateway” on the quality of referral letters; a retrospective time series cross sectional review

Background Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care. This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters. Methods Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral). Results Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of ‘past medical history’ (from 71% to 84%, p < 0.001) and ‘medication history’ (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods. Conclusion Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement

Specification: The Biggest Bottleneck in Formal Methods and Autonomy

Advancement of AI-enhanced control in autonomous systems stands on the shoulders of formal methods, which make possible the rigorous safety analysis autonomous systems require. An aircraft cannot operate autonomously unless it has design-time reasoning to ensure correct operation of the autopilot and runtime reasoning to ensure system health management, or the ability to detect and respond to off-nominal situations. Formal methods are highly dependent on the specifications over which they reason; there is no escaping the “garbage in, garbage out” reality. Specification is difficult, unglamorous, and arguably the biggest bottleneck facing verification and validation of aerospace, and other, autonomous systems. This VSTTE invited talk and paper examines the outlook for the practice of formal specification, and highlights the on-going challenges of specification, from design-time to runtime system health management. We exemplify these challenges for specifications in Linear Temporal Logic (LTL) though the focus is not limited to that specification language. We pose challenge questions for specification that will shape both the future of formal methods, and our ability to more automatically verify and validate autonomous systems of greater variety and scale. We call for further research into LTL Genesis

Comparative Performance Information Plays No Role in the Referral Behaviour of GPs

Comparative performance information (CPI) about the quality of hospital care is information used to identify high-quality hospitals and providers. As the gatekeeper to secondary care, the general practitioner (GP) can use CPI to reflect on the pros and cons of the available options with the patient and choose a provider best fitted to the patient’s needs. We investigated how GPs view their role in using CPI to choose providers and support patients. Method: We used a mixed-method, sequential, exploratory design to conduct explorative interviews with 15 GPs about their referral routines, methods of referral consideration, patient involvement, and the role of CPI. Then we quantified the qualitative results by sending a survey questionnaire to 81 GPs affiliated with a representative national research network. Results: Seventy GPs (86% response rate) filled out the questionnaire. Most GPs did not know where to find CPI (87%) and had never searched for it (94%). The GPs reported that they were not motivated to use CPI due to doubts about its role as support information, uncertainty about the effect of using CPI, lack of faith in better outcomes, and uncertainty about CPI content and validity. Nonetheless, most GPs believed that patients would like to be informed about quality-of- care differences (62%), and about half the GPs discussed quality-of-care differences with their patients (46%), though these discussions were not based on CPI. Conclusion: Decisions about referrals to hospital care are not based on CPI exchanges during GP consultations. As a gatekeeper, the GP is in a good position to guide patients through the enormous amount of quality information that is available. Nevertheless, it is unclear how and whether the GP’s role in using information about quality of care in the referral process can grow, as patients hardly ever initiate a discussion based on CPI, though they seem to be increasingly more critical about differences in quality of care. Future research should address the conditions needed to support GPs’ ability and willingness to use CPI to guide their patients in the referral process