Essential components of health assessment for older people in primary care: a cross-sectional survey of Australian general practitioners.

OBJECTIVE: To examine general practitioners' views about how health assessments for older people should be conducted. METHODS: General practitioners were randomly sampled from a national database of medical practitioners and invited to complete a survey. Survey items explored general practitioners' views about essential components of a 75+ Health Assessment and who should assess each component, consultation time, use of standardised templates and tools, and home visits. RESULTS: Overall, 185 (19.2%) general practitioners participated. Of 61 items presented, 24 were rated 'essential' by ≥70% of practitioners, with an average estimated consultation time of 65 minutes. Of the 24 essential items, it was perceived that 21 could be assessed by either a general practitioner or clinic nurse. Most practitioners indicated a standardised template (86%) and standardised tools for complex issues (79%) should be used, and home visits conducted (75%). CONCLUSIONS: General practitioners agreed on 24 items as essential for every health assessment, with assessments estimated to take more than one hour. Implications for public health: Increases to remuneration for prolonged assessments or mechanisms for improving efficiency and quality of assessments are needed. Acceptable mechanisms may include standardised patient-reported tools, standardised templates and the use of non-medical staff to assist with assessments.

The value of the physical examination in clinical practice: an international survey.

A structured online survey was used to establish the views of 2,684 practising clinicians of all ages in multiple countries about the value of the physical examination in the contemporary practice of internal medicine. 70% felt that physical examination was 'almost always valuable' in acute general medical referrals. 66% of trainees felt that they were never observed by a consultant when undertaking physical examination and 31% that consultants never demonstrated their use of the physical examination to them. Auscultation for pulmonary wheezes and crackles were the two signs most likely to be rated as frequently used and useful, with the character of the jugular venous waveform most likely to be rated as -infrequently used and not useful. Physicians in contemporary hospital general medical practice continue to value the contribution of the physical examination to assessment of outpatients and inpatients, but, in the opinion of trainees, teaching and demonstration could be improved.

Identifying educator behaviours for high quality verbal feedback in health professions education: literature review and expert refinement.

BACKGROUND: Health professions education is characterised by work-based learning and relies on effective verbal feedback. However the literature reports problems in feedback practice, including lack of both learner engagement and explicit strategies for improving performance. It is not clear what constitutes high quality, learner-centred feedback or how educators can promote it. We hoped to enhance feedback in clinical practice by distinguishing the elements of an educator's role in feedback considered to influence learner outcomes, then develop descriptions of observable educator behaviours that exemplify them. METHODS: An extensive literature review was conducted to identify i) information substantiating specific components of an educator's role in feedback asserted to have an important influence on learner outcomes and ii) verbal feedback instruments in health professions education, that may describe important educator activities in effective feedback. This information was used to construct a list of elements thought to be important in effective feedback. Based on these elements, descriptions of observable educator behaviours that represent effective feedback were developed and refined during three rounds of a Delphi process and a face-to-face meeting with experts across the health professions and education. RESULTS: The review identified more than 170 relevant articles (involving health professions, education, psychology and business literature) and ten verbal feedback instruments in health professions education (plus modified versions). Eighteen distinct elements of an educator's role in effective feedback were delineated. Twenty five descriptions of educator behaviours that align with the elements were ratified by the expert panel. CONCLUSIONS: This research clarifies the distinct elements of an educator's role in feedback considered to enhance learner outcomes. The corresponding set of observable educator behaviours aim to describe how an educator could engage, motivate and enable a learner to improve. This creates the foundation for developing a method to systematically evaluate the impact of verbal feedback on learner performance.

Unusual presentation of a common problem.

We report on an elderly lady with a large hiatus hernia presenting with presyncope and syncope associated with large meals. Though left atrial filling and mitral inflow was unimpaired, this case is interesting since the symptoms resolved with adjustment to meal size.

The effect of context on performance of an acute medical unit: experience from an Australian tertiary hospital.

OBJECTIVE: To ascertain the improvements in length of stay and discharge rates following the opening of an acute medical unit (AMU). METHODS: Retrospective cohort study of all patients admitted under general medicine from June-November 2008. Main outcome measures were length of stay in hospital and in the emergency department (ED). RESULTS: The length of time spent in the emergency department for those admitted to the AMU was significantly shorter than those admitted directly to a medical ward (6.83h v. 9.40h, P<0.0001). A trend towards shorter hospital length of stay continued after the AMU opened compared with the same period in the previous year (5.15 days (2.49, 11.57 CI) v. 5.66 days (2.76, 11.52 CI)). However, the number of ward transfers for a patient and the need to wait for a nursing home bed or public rehabilitation affected length of stay much more than the AMU. CONCLUSION: An AMU was successful in decreasing ED length of stay and contributed to decreasing hospital length of stay. However, we suggest that local context is crucially important in tailoring an AMU to obtain maximal benefit, and that AMUs are not a 'one size fits all' solution.

The problems of sleep for older women: changes in health outcomes.

OBJECTIVE: to identify the continuance of sleeping difficulty and medication use in a cohort of older Australian women from baseline to 3-year follow-up and to explore the relationship between these factors and health-related quality of life scores, falls and other health care use. METHOD: a 3-year longitudinal survey of 10,430 Australian women aged 70-75 years at baseline. These women were participants in the Australian Longitudinal Study on Women's Health randomly selected from the Australian Medicare database. RESULTS: a majority of women (63%) endorsed one or more items related to sleeping difficulty at 3-year follow-up: 33% reported one item only, 16% reported two or three items, and 14% reported more than three items; 4,194 (42.4%) reporting "waking in the early hours", 2,592 (26.0%) "taking a long time to get to sleep", 2,078 (21.0%) "sleeping badly at night", 1,072 (10.8%) "lying awake most of the night" and 1,087 (11.0%) "worry keeping you awake". Total scores on the Nottingham Health Profile sleep sub-scale ranged from 0-100 and were skewed to the right. The median score was 12.57. There was a strong statistical association between reporting sleeping difficulty at baseline and at follow-up. A total of 1,532 (15%) women reported use of sleeping medication at follow-up and women were 6.5 times more likely to report use if they also reported any item of sleep difficulty. There was a moderate level of agreement (88%, kappa=0.56) between taking sleeping medication within 4 weeks before the baseline survey and within 4 weeks before follow-up. On multivariate analysis, sleeping difficulty at baseline was negatively associated with general health perceptions, emotional role limitations and general mental health sub-scales of the Short-Form-36 Health Survey at follow-up; the use of sleep medication at baseline was negatively associated with physical functioning, bodily pain, vitality, social functioning and general mental health Short-Form-36 sub-scale scores. The use of sleep medication was also significantly associated with falls, accidents, and health care utilisation. CONCLUSION: sleeping difficulty is a common and persistent complaint among older women and is strongly associated with use of sleeping medications. Both behaviours are negatively associated with health status.