A standard set of person-centred outcomes for diabetes mellitus: results of an international and unified approach.

AIMS: To select a core list of standard outcomes for diabetes to be routinely applied internationally, including patient-reported outcomes. METHODS: We conducted a structured systematic review of outcome measures, focusing on adults with either type 1 or type 2 diabetes. This process was followed by a consensus-driven modified Delphi panel, including a multidisciplinary group of academics, health professionals and people with diabetes. External feedback to validate the set of outcome measures was sought from people with diabetes and health professionals. RESULTS: The panel identified an essential set of clinical outcomes related to diabetes control, acute events, chronic complications, health service utilisation, and survival that can be measured using routine administrative data and/or clinical records. Three instruments were recommended for annual measurement of patient-reported outcome measures: the WHO Well-Being Index for psychological well-being; the depression module of the Patient Health Questionnaire for depression; and the Problem Areas in Diabetes scale for diabetes distress. A range of factors related to demographic, diagnostic profile, lifestyle, social support and treatment of diabetes were also identified for case-mix adjustment. CONCLUSIONS: We recommend the standard set identified in this study for use in routine practice to monitor, benchmark and improve diabetes care. The inclusion of patient-reported outcomes enables people living with diabetes to report directly on their condition in a structured way.

How Fleet Bank fought employee flight.

In the late 1990s, Fleet Bank was facing high and rising employee turnover, particularly in its retail operations. Overall turnover had reached 25% annually, and among some groups, such as tellers and customer service reps, turnover was as high as 40%. Using a new methodology developed by Mercer Human Resource Consulting, Fleet set out to determine why so many employees were leaving and what could be done to retain them. It began examining data from HR, finance, operations, and sales about employee behavior and the factors that influence it in different locations and labor markets, departments or work groups, in positions with different pay and benefits, and under different supervisors. Fleet's analysis showed that people were leaving not so much for better pay--their personal testimony notwithstanding--but for broader experience, which they thought would enhance their marketability. Additionally, the analysis revealed a link between the turnover problem and the company's busy history of mergers and acquisitions. Fleet's mergers and acquisitions. frequently meant that it had to consolidate operations. That consolidation resulted in layoffs, which provoked higher levels of voluntary turnover, perhaps because remaining employees began worrying about their job security. While the obvious solution to the turnover problem might have been to compensate the remaining employees--say, with higher pay--the more effective and less costly solution, Fleet discovered, was to focus on employees' career opportunities within the company. Those who moved up the hierarchy, or who even made lateral moves, stayed longer. By offering better internal opportunities for career development, the bank was able to stanch much of the hemorrhaging in personnel. Its solutions required only modest investments, which in the end saved the company millions of dollars.

Therapeutic uses of humor.

This paper examines psychological aspects of humor, leading into a review of the role of humor in psychotherapy. Constructive and destructive aspects of humor in psychotherapy are listed and brief clinical examples from a case given.

Some sociocultural aspects of humour.

The social origins of laughter in homo sapiens, joking relationships and comic roles in both primitive and modern societies and reference group humour are all important to the psychiatrist in understanding the part played by humour in the social context presented by differing ethnic and social groups of patients. The use of humour by the medical profession, and particularly by the psychiatrist, is considered.

Management of depression in patients with advanced cancer.

OBJECTIVE: To formulate guidelines on the assessment, diagnosis and treatment of depressive symptoms in patients with advanced cancer, based on a review of the literature and clinical experience. DATA SOURCES: Articles from a range of international, peer-reviewed journals, texts by acknowledged experts and diagnostic manuals. STUDY SELECTION: The works cited focused either on the prevalence and diagnosis of depression in patients with cancer or related conditions or on the management or treatment of depressive symptoms arising in these patients. DATA EXTRACTION: Information was summarised and integrated into the management strategy. SYNTHESIS: There is an increased frequency of depressive-type symptoms in patients with cancer. In assessing the mood of these patients the physician needs to consider a wide range of factors. Diagnostic issues regarding depression in the medically ill are still being clarified. A good rapport with the patient and an understanding of the emotional conflicts engendered in the individual are important for good management. Active psychotherapeutic strategies include cognitive therapy techniques, management of self-defeating patterns of thought and low morale, and psychosocial group treatments. The side effects of antidepressants in the medically ill may preclude their use, although cyclic antidepressants in a lower dose range have been found to be useful. CONCLUSIONS: There is a need for more research into the diagnosis of depression in the medically ill and the use of antidepressants and counselling techniques in patients with cancer. The adequate management of depressed mood which occurs commonly in the patient with advanced cancer requires an integration of biological, psychological and social perspectives. Orchestrating the use of supportive measures, counselling and antidepressants requires both clinical skill and humanity.