A phase III randomized controlled trial of a stepped collaborative care intervention versus standard of care.
Jennifer L. SteelVincent ReyesLauren TerhorstCharles J. GeorgeJonas T. JohnsonMichael KrauzeJason BierenbaumNishant TagejaGauri KieferMarci L. NilsenGaurav GoelRobert VanderWeeleChristopher Ritchie MarshGopala RamineniDan P. ZandbergMichael H. AntoniSamer TohmeDavid A. Geller
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e24191 Background: The aims of this study were to screen patients for symptoms of depression, pain, and/or fatigue and test the efficacy of a stepped collaborative care (SCC) intervention compared to standard of care (SC). When compared to SC, we expected that the patients randomized to the SCC intervention would report greater improvements in patient quality of life (QoL) and lower health care utilization and costs. Family caregivers, of patients randomized to the SCC, were expected to have lower risk of cardiovascular disease when compared to family caregivers, of patients randomized to SC. Methods: Of the 459 patients and 211 caregivers enrolled in this trial, patients’ mean age was 66 years, the majority were female (56.2%) and Caucasian (92.6%). Family caregivers had a mean age of 62 years, the majority were female (69%) and Caucasian (87%). Patients were screened for clinical levels of depression, pain, and/or fatigue and then were randomized to the SCC intervention or SC arm (referral to a community provider for treatment). Family caregivers were administered questionnaires and provided blood and anthropometric data to assess risk of CVD using the ASCVD calculator. Family caregivers did not receive the intervention. Health care utilization was collected from the patients' medical record and activity-based costs were used to assess health care savings. Intent to treat analyses using general linear mixed models were employed to test the hypotheses. Results: General linear mixed models revealed an interaction of quadratic time by arm effect with patients who were randomized to the SCC intervention having greater 0-to-6-month improvement in overall QoL versus patients randomized to the SC arm [t(579) = 2.23, p = .0259]. No group difference was observed in 6-to-12 month change in QoL suggesting maintenance of gains were observed at 12 months [t(561) = -1.34, p > .10]. Multivariate analyses showed a similar pattern of more rapid gains in the subscales of QoL at 6-months in the patients randomized to the SCC intervention when compared to patients in the SC arm on the emotional well-being [t(1,856) = 2.27, p = 0.012], functional well-being [t(1, 891) = 1.73, p = 0.042]; and physical well-being subscales [t(1,777) = 1.84, p = 0.033]. Family caregivers, of patients who were randomly assigned to the SCC intervention, had lower lifetime cardiovascular risk, when compared family caregivers of patients who were randomized to the SC (uMV χ 2 =9.00, p = 0.027). Activity based costs savings of $12,546 per patient per year in activity-based costs were observed for patients randomized to the SCC intervention versus SC. The drivers of the activity-based cost savings appear to be reductions in complication and readmission rates. Conclusions: Cancer centers, and payors, interested in novel delivery and payment models may consider this integrated strategy to improve patient quality of life and save health care costs. Clinical trial information: NCT02944136 .Keywords:
Depression
Objective To evaluate the therapeutic effects of one visit root canal therapy(RCT) and several visit RCT for cracked teeth.Methods Cracked teeth with pulposis or apical disease were randomized to receive one visit RCTor several visit RCT,their responses were compared.Results The long-term therapeutic effects of one visit RCT were batter than those of several visit RCT,but the differences were not significant.The concomitant symptoms were significantly less and treatment time was significantly shorter in one visit RCT group as compared with several visit RCT group.Conclusion One visit RCT is recommended for the RCT of cracked teeth.
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To describe the general practitioners referral patterns. There is special emphasis in the delay between the referral and the first consultation with the specialist. Also we consider other aspects of the coordination between both levels of care.Cross-sectional study upon 8.095 referrals from 242 spanish doctors.The referral rate was 6.63%, higher in the 15-44 age group and also for men. We find a huge variability in the referral rates among doctors. The referral rates are higher to surgical specialties. The mean delay between referral and specialist appointment was 11 days. The general practitioners didn't receive communication from the specialists in 23.5 of the referrals.A considerable range of referral rates has been identified. There is a poor continuity and coordination in the patient care.
Patient referral
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Objective To investigate the role of referral doctors in enhancement of referral arrival rate of pulmonary tuber culosis patients.Methods Two counties with low referral arrival rate of tuberculosis cases were selected as the intervention county and the control county.Health education was implemented in intervention county with tuberculosis patients required re ferral,while the control county maintained the original operating mode,and then 150 tuberculosis cases reported by medical in stitutions in the two counties were investigated by questionnaire survey.Results The referral arrival rate of tuberculosis pa tients in intervention county increased from 23.8% to 66.7%,significantly higher than that before intervention(χ2 = 83.7,P 0.05) and also significantly higher than in control county(41.3%,χ2 = 19.38,P0.05).Besides,81.3% of patients in interven tion county obtained the TB control knowledge from health education by referral doctors before referral,significantly higher than that of control county(χ2 = 53.7).The cause of tuberculosis cases failed to referral was due to unfamiliar of TB control insti tutions accounted for 46.9%(intervention county) and 51.3%(control county),and the cause of other tuberculosis cases failed to referral was due to unclear explanation by the referral doctors accounted for 40.8% and 30.6% in the intervention county and control county,respectively.Conclusions Health education given by referral doctors before referral is one of the important measures for enhancing the referral arrival rate of tuberculosis patients.Thus the effort of upgrading the health education level of referral doctors is indicated.
Tuberculosis control
Tuberculosis prevention
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Background. In Saudi Arabia, the mortality of diabetes is currently reported at 6%. A well-administered referral system is crucial in aiding the management of this disease. Method. A single reviewer employed a systematic approach to searching the literature databases with regard to the question: what are the attributes of referral systems in Saudi Arabia for patients with type 2 diabetes (T2D)? The results were analysed in order to provide recommendations to improve the Saudi health system. Results. Twelve primary studies were identified from a systematic search. Overall, the 12 studies did not clearly mention any of the factors of a good referral system. The referral problems identified by this study included patients’ unnecessary requests for referral, unstructured referral letters, and unclear dissemination guidelines for referral. Conclusions. This research attempted to identify the efficiency of the referral processes that were implemented for patients with T2D. The majority of the included studies were completely silent on the main referral factors for patients. If this review is representative of the referral system in Saudi Arabia, then, in the context of T2D, current referrals are unsafe. Further research on the quality of the referral system, taking into account at least some of the WHO referral guidelines, is required.
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Objective To explore and discuss contradictions and problems existing in the two-way referral system through analyzing the situation of patients' referral between Sichuan Provincial People's Hospital and 21 community health service centers in Chengdu,and propose measures and methods to further improve the two-way referral system.Methods Totally 3652 patients required referral from April 2010 to March 2011(2 635 patients from the hospital to community medical service centers and 1017 in a opposite direction) were selected.The reasons for referral and the factors for successful and unsuccessful referral were analyzed.The on-site interviews were conducted among doctors,department directors,and medical administrators from both the hospital and the centers.The talking topics included the design of bi-directional referral system,policy support from the government,current status of two-way referral and the main factors restricting the implementation of bi-directional referral system.Results Among the 2635 patients needed to have a referral from the hospital to centers(downward referral) for rehabilitation only 50 were successfully transferred,with a successful referral ratio of 52.7∶ 1.However,concurrently 1017 patients were transferred from the 21 centers to the hospital(upward referral).The ratio of upward referral to downward referral was 20.3∶ 1.There are a total of 1623 beds in all the 21 centers,however,the average utilization rate of beds was only 70.65%,as contrasted with that of 112.35% in the hospital.Majority of the interviewers believed that the factors impacting the implementation of two-way referral included un-smooth communication of medical information,no criteria and process of referral so far,shortage of mutual trust between the two referral parties,and non-full consideration of the two-way referral factors by the medical authorities in formulating the local health plan.Conclusion Although the two-way referral system has been implemented in Chengdu area,the rate of successful transfer is still lower,especially for the patients needing downward referral.
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無作為化比較試験（RCT, randomized controlled trial）が新しい治療法の効果を評価するためにヒトに施される実験であり，かつまた，それが最も質の高い科学的なエビデンスを提供してくれる唯一の研究デザインであることは世界的に広く認められた事実である．一方，日本では，RCT に対する関心とその重要性への認識は低く，薬効評価の分野でも質の高い RCT はきわめて少なかった．最近の科学的根拠に基づく医療（EBM）の流行により RCT に対する関心は高まっているものの，RCT を正しく理解して実践できる臨床医，製薬メーカの臨床開発担当者は少ない．このことは補完代替医療の評価においても全く同様にあてはまる．RCT を正しく理解し，デザインし，その結果を正しく評価できる研究者，実務家の養成は急務である．本小論では，RCT とは何か，RCT をデザインする上で必要不可欠な統計学的考え方を解説する．
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Referral rates and urgency of referral to hospital by six pairs of trainers and trainees were compared over one month in 1986. From 5846 consultations, 327 resulted in referral to hospital. Overall, the referral rates was low at 5.6 per 100 consultations; however, there was considerable variation in individual referral rates with trainees tending to follow their trainer's referral patterns, despite statistical adjustment for sharing the same practice. This paper critically examines the wisdom of using general practitioner referral rates for the purpose of resource allocation and education.
Trainer
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OBJECTIVES--To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines. SETTING--Practices within Cambridge Health Authority and Addenbrooke9s Hospital, Cambridge. MAIN OUTCOME MEASURES--Data on practice referral rates from hospital computers, inappropriate referrals as judged by hospital consultants, and inappropriate referrals as judged against referral guidelines which had been developed locally between general practitioners and specialists. Effect of referral guidelines on referral patterns as judged by general practitioners using the guidelines in clinical practice. RESULTS--There was 2.5-fold variation in referral rates among general practices. According to the specialists, 9.6% (95% confidence interval 6.4% to 12.9%) of referrals by general practitioners and 8.9% (2.6% to 15.2%) of referrals from other specialists were judged possibly or definitely inappropriate. Against locally determined referral guidelines 15.9% of referrals by general practitioners were judged possibly inappropriate (11.8% to 20.0%). Elimination of all possibly inappropriate referrals could reduce variation in practice referral rates only from 2.5-fold to 2.1-fold. An estimate of the effect of using referral guidelines for 60 common conditions in routine general practice suggested that application of guidelines would have been unlikely to reduce rates of referral in hospital (95% confidence interval -4.5% to 8.6% of consultations resulting in referral). CONCLUSION--The variation in referral rates among general practitioners in Cambridge could not be explained by inappropriate referrals. Application of referral guidelines would be unlikely to reduce the number of patients referred to hospital.
Variation (astronomy)
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Objective To understand the present situation of medical referral in community health service (CHS) institutions of Beijing and the demands for referral criteria.Methods A questionnaire survey was conduced among trainees of training program for key general practitioners form CHS institutions in Beijing.Results The present situation of referral was unsatisfactory;with a lower referral rate.The major problems were unsmooth referral channel between the higher level hospital and CHS institutions,more up-referral from CHS institutions to higher-level hospital,and no unified referral criteria.General practitioners had an urgent demand for referral criteria.Conclusion In order to improve the two-way referral system,the referral guidelines and referral indicators or main symptoms of diseases for CHS institutions should be made as soon as possible.
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Objective: To explore the implementation and nursing experience of community two-way referral system.Methods: The referral rate and readmission rates of 240 cases patients were analyzed and discussed before and after the community two-way referral system,then gave the advice according to the results.Results: The referral rate of the patients after the community two-way referral system was 68.3%(82/120),which was higher than the rate before 30.8%(37/120),there was a significant difference between them(P0.01).The readmission rate also reduced after the community two-way referral system with it was from 63.7% to 22.1%.Conclusion: The performance of community two-way referral system is in favor of utilizing the medical resources reasonably.Meanwhile,it is benefit for the development of community hospital.
Community hospital
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