referral and consultation

An evidence-based review of our current knowledge of both pharmacologic and non-pharmacologic treatments for people suffering from PTSD. James W. Mold, MD, MPH

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Objectives: Identify and abstract data from posttraumatic stress disorder (PTSD) treatment randomized controlled trials (RCTs) to update the PTSD Trials Standardized Data Repository (PTSD-Repository) with data on PTSD and mental health, including suicide-related outcomes and substance use.

Data sources: We searched PTSDpubs, Ovid® MEDLINE®, Cochrane CENTRAL, PsycINFO®, Embase®, CINAHL®, and Scopus® for eligible RCTs published from 1980 to May 22, 2020.

Review methods: In consultation with the National Center for PTSD (NCPTSD), we updated the PTSD-Repository by expanding inclusion criteria to RCTs targeting comorbid PTSD/substance use disorder (SUD) and adding data elements. The primary publication for each RCT was abstracted; data and citations from secondary publications (i.e., companion papers) appear in the same record. We assessed risk of bias (ROB) for all studies in the PTSD-Repository. We undertook an exploratory assessment of an expanded ROB system developed with guidance from a Technical Expert Panel and NCPTSD, which was pilot tested on a small subset of studies.

Results: We identified 47 new RCTs of interventions for PTSD and 21 RCTs for comorbid PTSD/SUD, resulting in 389 included studies published from 1988 to 2020. Psychotherapy interventions were the most common (63%), followed by pharmacologic interventions (25%). Most studies were conducted in the United States (62%) and had sample sizes ranging from 25 to 99 participants (60%). Approximately half of studies enrolled community participants (55%), and most were conducted in the outpatient setting (72%). Studies typically enrolled participants with a mix of trauma types (53%). Most RCTs (60%) were rated as having a medium ROB, and only 6 percent were rated as having a low ROB. Our pilot testing of an expanded ROB assessment tool emphasized more detailed assessment of elements, including: (1) methods for managing missing data, including both dropout from treatment and missing measurements (i.e., loss to followup); (2) differential assessment of subjective and objective outcomes; and (3) consideration of a five-category overall rating system.

Conclusions: The PTSD-Repository is a comprehensive database of data from PTSD trials. The PTSD-Repository allows clinical, research, education, and policy stakeholders to understand current research on treatment effectiveness and harms, and enable informed decisions about future research, mental health policy, and clinical care priorities. This report updates the studies and variables included in the PTSD-Repository to include recently published trials, interventions targeting comorbid PTSD/SUD, variables related to comorbidities such as suicide and SUDs, and ROB assessment.

Author/s:

O'Neil, M. E., Cheney, T. P., Hsu, F. C., Carlson, K. F., Hart, E. L., Holmes, R. S., Murphy, K. M., Graham, E., Cameron, D. C., Kahler, J., Lewis, M., Kaplan, J., McDonagh, M. S.

Sacral Neuromodulation for Neurogenic Lower Urinary Tract Dysfunction

Aubrey Delammermore — Tue, 25 Oct 2022 05:00:00 +0000

Date Added:

October 25, 2022

Journal/Publication:

New England Journal of Medicine Evidence

Publisher:

Massachusetts Medical Society

Publication Date:

July 7, 2022

Issue:

Volume:

URL:

Sacral Neuromodulation for Neurogenic Lower Urinary Tract Dysfunction

Type:

Clinical Research Results

Format:

Article

Keywords

Sacral Neuromodulation

Lower Urinary Tract Dysfunction

referral and consultation

Odds Ratio

Randomized Controlled Trials as Topic

MeSH

Electric Stimulation Therapy

Many patients with various forms of neurogenic bladder (neurogenic lower urinary tract dysfunction) appear to benefit significantly from sacral neuromodulation, a fairly simple, reversible surgical procedure. James W. Mold, MD, MPH

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BACKGROUND
Neurogenic lower urinary tract dysfunction (NLUTD) is a highly prevalent and disabling condition; nevertheless, standard treatments often remain unsatisfactory. Sacral neuromodulation (SNM) is a well-established therapy for non-NLUTD, but there is a lack of randomized controlled trials to show benefit in patients with NLUTD.

METHODS
For this sham-controlled, double-blind, multicenter trial, patients with refractory NLUTD (and intended SNM) were recruited at four Swiss SNM referral centers. After lead placement into the sacral foramina S3 (rarely, S4), all participants underwent SNM testing. If successful (≥50% improvement in key bladder diary variables), the neurostimulator was implanted for permanent stimulation. For 2 months, neuromodulation was optimized using subsensory stimulation with individually adjusted parameters. Thereafter, the neurostimulator remained on or was switched off (1:1 random allocation to group SNM ON or SNM OFF, respectively) for 2 months, followed by a neurourologic reevaluation. The primary outcome was success, as defined above, of SNM compared with baseline.

RESULTS
Of 124 patients undergoing SNM testing, 65 (52%) had successfully improved lower urinary tract function. Of these, 60 patients (median age, 49.5 years; 43 women) were randomly assigned to the intervention. After 2 months of intervention, the SNM ON group demonstrated a success rate of 76%. In the SNM OFF group, 42% of patients showed sustained SNM effects despite their neurostimulator being switched off during the last 2 months (odds ratio, 4.35; 95% confidence interval, 1.43 to 13.21; P=0.009). During the entire study period, there were 11 adverse events (6 dropouts; no dropouts during the intervention phase).

CONCLUSIONS
SNM effectively corrected refractory NLUTD in the short term in well-selected neurologic patients. (Funded by the Swiss National Science Foundation, Vontobel–Stiftung, Gottfried und Julia Bangerter–Rhyner Stiftung, Dr. Urs Mühlebach, and the Swiss Continence Foundation; ClinicalTrials.gov number, NCT02165774.)

Author/s:

Liechti, M. D., van der Lely, S., Knüpfer, S. C., Abt, D., Kiss, B., Lietner, L., Mordasini, L., Tornic, J., Wöllner, J., Mehnert, U., Bachmann, L. M., Burkhard, F. C., Engeler, D. S., Pannek, J., Kessler, T. M.

Revising the advanced access model pillars: a multimethod study

Aubrey Delammermore — Sat, 24 Sep 2022 05:00:00 +0000

Date Added:

September 24, 2022

Journal/Publication:

CMAJOpn

Publisher:

CMA Impact Inc

Publication Date:

September 6, 2022

Issue:

Volume:

Pages:

E799-E806

URL:

Revising the advanced access model pillars: a multimethod study

Type:

Practice Management Research Results

Format:

Article

DOI (1):

10.9778/cmajo.20210314

Keywords

Family Physicians

social workers

referral and consultation

nurse practitioners

scheduling models

MeSH

primary health care

health services accessibility

access to information

Patient-Centered Care

Population Health

A highly conceptual report on the design and improvement of advance access scheduling models based upon research and clinical and administrative experience. James W. Mold, MD, MPH

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Background: The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care.

Methods: This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content.

Results: The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model (“Appointment system” and “Interprofessional practice”), 1 was merged with a revised pillar (“Develop contingency plans” with “Planning of needs and supply”) and 1 underwent major transformations (“Backlog reduction” to “Continuous adjustment”). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content.

Interpretation: The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice.

Timely access is a cornerstone of strong primary health care and a key component of a patient-centred medical home for ensuring population health.1 Numerous innovations have been implemented to improve timely access,2 with one of the most recommended around the world being the advanced access model, also called open access.2,3 Based on greater accessibility linked with patients’ relational and informational continuity with a primary health care professional or team, the advanced access model aims to ensure that patients obtain access to health care services at a time and date convenient for them when needed, regardless of the urgency of the demand.4 Originally developed in the United States in the early 2000s, advanced access is defined by Murray and Berwick as having 5 pillars: balance supply and demand, reduce the backlog of previously scheduled appointments, review the appointment system, integrate interprofessional practice and develop contingency plans.5,6 Several scientific papers on the foundations of advanced access have been published over the past 20 years, and its benefits have been reported in many countries, including the US, the United Kingdom and Canada.6–9

Over the last 2 decades, primary health care practice has evolved to increase interdisciplinarity in clinical teams. Thus, the need for a model that incorporates new practices and professionals has necessitated development of an updated advanced access model. Furthermore, advanced access was originally developed in a context that prioritized implementing a new way of doing, with less emphasis on the ongoing practice and sustainability of the model.10,11 However, changes in primary health care practice require revisions to the advanced access model to adapt it to the contemporary context.

In this study, we redefine the pillars and subpillars of the advanced access model by integrating an interdisciplinary team–based focus, while considering the integration of primary health care professionals, such as nurse practitioners, registered nurses, social workers and other allied professionals, in primary health care practices. The objective of this study was to revise and operationalize the pillars and subpillars of the advanced access model.

Author/s:

Breton, M., Gaboury, I., Beaulieu, C., Sasseville, M., Hudon, C., Malham, S. A., Duhoux, A., Rodrigues, I., Haggerty, J.

Revising the advanced access model pillars: a multimethod study

Aubrey Delammermore — Sat, 24 Sep 2022 05:00:00 +0000

Date Added:

September 24, 2022

Journal/Publication:

CMAJOpn

Publisher:

CMA Impact Inc

Publication Date:

September 6, 2022

Issue:

Volume:

Pages:

E799-E806

URL:

Revising the advanced access model pillars: a multimethod study

Type:

Practice Management Research Results

Format:

Article

DOI (1):

10.9778/cmajo.20210314

Keywords

Family Physicians

social workers

referral and consultation

nurse practitioners

scheduling models

MeSH

primary health care

health services accessibility

access to information

Patient-Centered Care

Population Health

A highly conceptual report on the design and improvement of advance access scheduling models based upon research and clinical and administrative experience. James W. Mold, MD, MPH

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Author/s:

Breton, M., Gaboury, I., Beaulieu, C., Sasseville, M., Hudon, C., Malham, S. A., Duhoux, A., Rodrigues, I., Haggerty, J.

Guide to Enhancing Referrals and Consultations Between Physicians

Tracy Ashby — Fri, 01 Feb 2019 06:00:00 +0000

Date Added:

February 1, 2019

Publisher:

The College of Family Physicians of Canada

Publication Date:

October 1, 2009

Type:

Practice Management Reviews and Guidelines

Format:

Article

Keywords

referral and consultation

patient care

physicians

MeSH

physicians, family

referral and consultation

patient care

This is a summary of consultation and referral best practices from the College of Family Physicians of Canada.

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Access to care is a challenge for many of our patients. The College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (Royal College) recognize that every possible measure must be taken to help ensure access to timely and quality medical and other health care service.
As part of ongoing efforts, the CFPC and the Royal College released a conjoint paper in 2006, to address the issue of intra-professional relationships between physiciansi. This paper identifies a number of issues and recommendations to improve patient care and professional satisfaction. The referral-consultation process is chief among the areas addressed in follow up to this conjoint paper.
There is growing knowledge and many new approaches developing in various regions of the country to improve the referral-consultation processes of care between referring and consulting physicians.
This guide on enhancing referrals and consultations between physicians is not intended to replace instruments already in place. It is complementary and may also help fill gaps where there are few or no tools in place to support good referrals and consultations, both within as well as between community and hospital settings. It is hoped that physicians will find this reference to be a valuable addition to practice.