Peter W. Moorman

Shared care for diabetes: supporting communication between primary and secondary care

OBJECTIVE To assess the effects on information exchange of electronic communication between physicians co-treating diabetic patients. DESIGN Comparison of traditional paper-based communication for reporting and electronic communication. SETTING General practitioners and an internal medicine outpatient clinic of an urban public hospital. SUBJECTS A total of 275 diabetic patients, and the 32 general practitioners and one internal medicine consultant who cared for them. INTERVENTION An electronic communication network, linking up the computer-based patient records of the physicians, thus enabling electronic data interchange. MAIN OUTCOME MEASURES Number of letters sent and received per year by the general practitioners, the number of diabetes-related parameters (e.g. results of laboratory tests) in the patient records, and HBA1C levels. RESULTS INTERVENTION GPs received more messages per year (1.6 per patient) than control GPs (0.5 per patient, P<0.05). Significant higher availability (P<0.05) was achieved for data on HBA1C levels, fructosamine levels, blood pressure measurements, cholesterol levels, triglyceride levels and weight measurements. INTERVENTION patients showed a slight but significant decrease of HBA1C levels in the second semester of 1994 (from 7.0 to 6.8, P = 0.03), control patients also showed a slightly decreased group mean, but this change was not significant (from 6.6 to 6.5, P = 0.52). The magnitudes of these mean differences, however, were not significantly different (intervention group: 0.21; control group: 0.12, P = 0.68). CONCLUSIONS The electronic communication network for exchanging consultation outcomes significantly increased frequency of communication and the availability of data to the general practitioner on diagnostic procedures performed in the hospital, thus providing more complete information about the care that patients are receiving. A large-scale experiment over a longer period of time is needed to assess the effects of improved communication on quality of care.

Impact on Quality of Life of a Telemedicine System Supporting Head and Neck Cancer Patients: A Controlled Trial During the Postoperative Period at Home

OBJECTIVES Telemedicine applications carry the potential to enhance the quality of life of patients, but studies evaluating telemedicine applications are still scarce. The evidence regarding the effectiveness of telemedicine is limited and not yet conclusive. This study investigated whether telemedicine could be beneficial to the quality of life of cancer patients. DESIGN AND MEASUREMENTS Between 1999 and 2002, we conducted a prospective controlled trial evaluating the effects of a telemedicine application on the quality of life of patients with cancer involving the head and neck, using quality of life questionnaires that covered 22 quality of life parameters. All patients had undergone surgery for head and neck cancer at the Erasmus MC, a tertiary university hospital in The Netherlands. Patients in the intervention group were given access to an electronic health information support system for a period of six weeks, starting at discharge from the hospital. RESULTS In total, we included 145 patients in the control group and 39 in the intervention group. At 6 weeks, the end of the intervention, the intervention group had significantly improved QoL in 5 of the 22 studied parameters. Only one of these five quality of life parameters remained significantly different at 12 weeks. CONCLUSIONS This study adds to the sparse evidence that telemedicine may be beneficial for the quality of life of cancer patients.

The evidence for pharmacologic treatment of neuropathic cancer pain: Beneficial and adverse effects

CONTEXT The prevalence of neuropathic pain in patients with cancer pain has been estimated to be around 40%. Neuropathic pain may be caused by tumor invasion and is considered as mixed nociceptive-neuropathic pain, or caused by an anticancer treatment and considered as purely neuropathic pain. The use of adjuvant analgesics in patients with cancer is usually extrapolated from their efficacy in nononcological neuropathic pain syndromes. OBJECTIVES In this systematic review, we sought to evaluate the evidence for the beneficial and adverse effects of pharmacologic treatment of neuropathic cancer pain. METHODS A systematic review of the literature in PubMed and Embase was performed. Primary outcome measures were absolute risk benefit (ARB), defined as the number of patients with a defined degree of pain relief divided by the total number of patients in the treatment group, and absolute risk harm (ARH), defined as the fraction of patients who dropped out as a result of adverse effects. RESULTS We identified 30 articles that fulfilled our inclusion criteria. Overall, ARB of antidepressants, anticonvulsants, other adjuvant analgesics, or opioids greatly outweighed ARH. There were no significant differences in ARB or ARH between the four groups of medication or between patients with mixed vs. purely neuropathic pain. Because of the low methodological quality of the studies, we could not draw conclusions about the true treatment effect size of the four groups of medications. CONCLUSION Once a diagnosis of neuropathic pain has been established in patients with cancer, antidepressants, anticonvulsants, or other adjuvant analgesics should be considered in addition to or instead of opioids.

Electronic Messaging Between Primary and Secondary Care: A Four-year Case Report

OBJECTIVE To observe how electronic messaging between a hospital consultant and general practitioners (GPs) in 15 practices about patients suffering from diabetes evolved over a 3-year period after an initial 1-year study. DESIGN Case report. Electronic messages between a hospital consultant and GPs were counted. The authors determined whether a message sent by the consultant was integrated into the receiving GPs electronic medical record system. After the observation period, the GPs answered a questionnaire. MEASUREMENTS The number of electronic messages and the percentage of messages integrated into the electronic medical record. RESULTS The volume of messages was maintained during the 3 years after the original study. In the original study, the percentage of the messages integrated by the GPs increased during the year. After that study, however, seven GPs stopped integrating data from messages. The extent to which received messages were integrated varied widely among practices. CONCLUSION The authors conclude that extrapolation of the results of the original study would have led to incorrect conclusions. Although the volume of messages remained stable after the original study, GPs changed their method of handling messages. Initially, all GPs used the opportunity to copy data from the messages into their own records. At the end of the observation period (that is, the 3 years after completion of the original study), more than 50 percent of GPs had ceased copying data from the messages into their own records. The majority of GPs, however, wanted to expand the use of electronic messaging.

An automated algorithm to preselect patients to be assessed individually in point prevalence surveys for hospital-acquired infections in surgery.

In this pilot study, we evaluate an algorithm that uses predictive clinical and laboratory parameters to differentiate between patients with hospital-acquired infection (HAI) and patients without HAI. Seventy-four percent of the studied population of surgical patients could be reliably (negative predictive value of 98%) excluded from detailed assessment by the infection control practitioner.

Descriptive features of gastric ulcers: do endoscopists agree on what they see?

BACKGROUND Little is known about the interobserver variation between endoscopists on descriptive morphologic features. METHODS This study describes the agreement among 10 endoscopists on their description of 12 morphologic features, using 10 photographs of gastric ulcers, and on their eventual interpretation. The endoscopists used a form with predefined options for description. RESULTS Kappa value was on average 0.36 for descriptive features and 0.31 for interpretation. The proportion of endoscopists agreeing on descriptive features was on average 84%, and 81% on interpretations. The chance of an endoscopist describing all 12 morphologic features of an ulcer on a photograph exactly the same as a colleague ranged from 4% to 46% (average 15%). A positive correlation between agreement in description and interpretation (0.75, p < 0.05) was found. CONCLUSIONS These results indicate a poor agreement between endoscopists in their translation of visual observations into descriptive terms. The positive correlation between agreement in description and interpretation suggests disagreement in description as an important cause for disagreement in interpretation. We believe that the use of more explicit descriptive terms will improve agreement in description and in subsequent interpretation.