Cost-effectiveness of referral for generic care or problem-solving treatment from community mental health nurses, compared with usual general practitioner care for common mental disorders: Randomised controlled trial.

BACKGROUND: UK general practitioners (GPs) refer patients with common mental disorders to community mental health nurses. AIMS: To determine the effectiveness and cost-effectiveness of this practice. METHOD: Randomised trial with three arms: usual GP care, generic mental health nurse care, and care from nurses trained in problem-solving treatment; 98 GPs in 62 practices referred 247 adult patients with new episodes of anxiety, depression and life difficulties, to 37 nurses. RESULTS: There were 212 (86%) and 190 (77%) patients followed up at 8 and 26 weeks respectively. No significant differences between groups were found in effectiveness at either point. Mean differences in Clinical Interview Schedule - Revised scores at 26 weeks compared with GP care were -1.4 (95% CI -5.5 to 2.8) for generic nurse care, and 1.1 (-2.9 to 5.1) for nurse problem-solving. Satisfaction was significantly higher in both nurse-treated groups. Mean extra costs per patient were 283 pound (95% CI154-411) for generic nurse care, and 315 pound (183-481) for nurse problem-solving treatment. CONCLUSIONS: GPs should not refer unselected patients with common mental disorders to specialist nurses. Problem-solving should be reserved for patients who have not responded to initial GP care.

Educating future physicians for Ontario.

In 1987, Ontario's physicians conducted a strike, ultimately not successful, over the issue of "extra billing." The fact that the Ontario public did not support this action reflected a major gap between the profession's view of itself and the public's view of the profession. In 1990, the province's five medical schools launched a collaborative project to determine more specifically what the people of Ontario expect of their physicians, and how the programs that prepare future physicians should be changed in response. The authors report on the first five years of that ongoing project. Consumer groups were asked to state their views concerning the current roles of physicians, future trends that would affect these roles, changes in roles they wished to see, and suggestions for changes in medical education. Methods used included focus groups, key informant interviews, an extensive literature review, and surveys, including a survey of health professionals. Concurrently, inter-university working groups prepared tools and strategies for strengthening faculty development, assessing student performance, and preparing future leadership for Ontario's medical education system. Eight specific physician roles were identified: medical expert, communicator, collaborator, health advocate, learner, manager ("gatekeeper"), scholar, and "physician as person." Educational strategies to help medical students learn to assume these eight roles were then incorporated into the curricula of the five participating medical schools. The authors conclude that the project shows that it is feasible to learn specifically what society expects of its physicians, to integrate this knowledge into the process of medical education reform, and to implement major curriculum changes through a collaborative, multi-institutional consortium within a single geopolitical jurisdiction.

The scalability of the Rivermead Motor Assessment in acute stroke patients.

OBJECTIVE: To examine the scalability of the Rivermead Motor Assessment with hospitalized acute stroke patients. DESIGN: This was a prospective study of hospitalized stroke patients. SUBJECTS: Fifty-one selected stroke patients, including those over the age of 65, were assessed at one, three and six weeks post-stroke using the Rivermead Motor Assessment. Coefficients of scalability and reproducibility were calculated for each of the three sections of the Rivermead Motor Assessment at each assessment. RESULTS: The items in the gross function and arm sections met scaling criteria at all three assessments which meant that they were in appropriate order of difficulty. There was an overall increase in the proportion of subjects passing each item at successive assessments, suggesting that patients in the study were recovering. The leg and trunk section did not meet scale criteria with these acute stroke patients. CONCLUSIONS: We recommend that only the gross function and arm sections should be used as hierarchical scales with selected acute stroke patients. The leg and trunk section should only be used as an assessment checklist.

The scalability of the Rivermead Motor Assessment in nonacute stroke patients.

OBJECTIVE: To examine the scalability of the Rivermead Motor Assessment (RMA) with nonacute stroke patients in the community. DESIGN: This was a prospective study of the patients after discharge from hospital. All subjects were assessed on the RMA at six and 12 months after discharge home from hospital. Coefficients of scalability and reproducibility were calculated for each of the three sections of the RMA at each assessment. SUBJECTS: Subjects were nonacute stroke patients aged 65 years and over, nonacute stroke patients aged under 65 years, and a selected group of those aged under 65 years. RESULTS: Only the items in the gross function section met scaling criteria with nonacute strokes in both age groups, which suggests that the items in this section were in appropriate order of difficulty. The items in the leg and trunk section were not in hierarchical order and were in fact closer to scaling if the present order were reversed. CONCLUSIONS: The clinical and research value of the RMA, as an ordered scale, are questioned. Changes in treatment styles and philosophies may mean that some of the items themselves are out-dated.

New approaches to addressing information needs in local public health agencies.

For local Public Health agencies to be fully responsive to community needs, staff must have ready access to up-to-date and accurate information. During the last several years, the Hamilton-Wentworth Department of Public Health Services (DPHS), a Teaching Health Unit affiliated with McMaster University, has been developing new information services including establishment of a specialized library on site; education sessions on the use of information stored in this library and in the Hamilton-Wentworth Health Library Network; innovative approaches to tailoring information services to staff needs including on-site access to on-line literature databases; and establishment of a group to retrieve and report community health data. In the initial three years of operation, surveys of Hamilton-Wentworth staff and a comparison health unit (Niagara) revealed that staff most frequently sought information from managers and support staff, as well as from personal books, articles and journals. Over half (57%) of the Hamilton-Wentworth staff reported use of the DPHS library, whereas 28% of Niagara Regional Health Unit staff reported use of their library. Other information services, for example, bibliographic indexes on population health, were less frequently used. Plans to increase their use are discussed.

Development of a neonatal case-mix classification.

This article introduces a neonatal classification based on latent class analysis. The neonatal classification generates five distinct classes ranging from the normal-birth-weight, full-term, healthy baby to the low-birth-weight preterm infant with many life-threatening problems. Unlike several suggested neonatal classifications, latent class analysis accommodates the range and severity of illness typically encountered in neonatal populations. It also provides a classification based solely on the personal characteristics of the newborn that can be used to investigate variation in the use of neonatal services.

Influence of maternal age, parity and social class on perinatal mortality in Scotland: 1960-82.

PIP: This study examines secular changes in the influence of maternal age, parity and social class on perinatal mortality in Scotland. Using cross-sectional national data on all Scottish legitimate births the effects of these factors are estimated on the risk of stillbirths, neonatal and perinatal deaths, and the extent to which the current pattern of relative risks in the early 1980s has changed over the past 2 decades is investigated. Social class is used as a crude measure of relative as opposed to absolute differences in socioeconomic conditions which may influence reproductive outcomes. The effects of age, parity and social class are estimated using logistic models. The most parsimonious model adequately describing the data is provided by a main effects model without interactions. Despite changes in reproductive behavior, improved access to maternity services and more effective perinatal care, the influence of maternal age and social class on perinatal mortality remained unchanged between 1960 and 1982. Although the absolute risks of stillbirths and neonatal deaths declined in all maternal age groups, this improvement was not accompained by a significant change in the relative risks traditionally associated with age. Despite no significant changes in the traditional J-shaped association between parity and stillbirths, cross-sectional analysis shows that in the early 1980s the risk of both neonatal and perinatal deaths decreased as parity increased. This finding is consistent with the pattern of risks observed in longitudinal studies and retrospective surveys of reproductive histories. In view of the stability of age, parity and social class effects on the risk of perinatal mortality, little if any of the overall decrease in Scottish stillbirth and neonatal death rates can be attributed to a significant narrowing of relative risks. The results suggest that the attributable risk of high maternal age or low social class on perinatal mortality is negligible. Future improvements in perinatal mortality are thus likely to result from a continuation of the uniform decrease in perinatal mortality for women of all ages, parities and social classes and not from a diminishing of differences in relative risks which are now virtually identical for a large and growing % of women in Scotland.^ieng

Perinatal mortality in Scotland: 1970-9.

An examination of the recent decline in perinatal mortality in Scotland during the 1970s showed that despite substantial changes in fertility and the demographic pattern of births, differences in the age, parity, and social class composition of the obstetric population in this decade accounted for just 7% of the overall improvement in perinatal mortality between 1970 and 1979. The general pattern of relative risks associated with maternal age, parity, and social class remained largely unchanged. Marginal changes in the birthweight distribution, however, were sufficient to account for 13% of the reduction in perinatal mortality. The low birthweight infant, especially those weighing under 1500 g, assumed increasing importance as a factor in perinatal mortality owing to a progressive worsening in the relative risk of perinatal mortality associated with low birth weight. Although regional differences in perinatal mortality persisted over this period, there occurred some lessening of the traditional inequality between western and eastern parts of the country. Finally, registered causes of perinatal mortality are reviewed. In the absence of other explanations the results of this analysis, collectively, suggest that much of the recent decline in perinatal mortality was perhaps due to changes in obstetric practice and in the clinical management of neonatal morbidity.