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Saturday, 2 November 2013

Bridging the care transition gap: how healthcare reform is drivng better care management transitions.

Bridging the care transition gap: how healthcare reform is driving better care management transitions.

Will 2012 be the year of better care transitions? Many of the pieces are in place to make that happen, although there is still much work to be done to remedy this persistent--and multi-faceted--problem. 

A conference hosted by Kaiser Permanente in Washington, D.C., last October demonstrated the complexity of the care transitions problem. The meeting identified key areas of focus, including the discharge process, medication reconciliation, information flow, and patient and caregiver interaction. At the conference, Farzad Mostashari, M.D., national coordinator for health IT, urged the participants to embrace technology as a facilitator for improving care transitions, and he made a business case, as fee-for-service payment models are replaced by new models of payment. 


Harry Greenspun, M.D., senior adviser for healthcare transformation and technology at the Deloitte Center for Health Solutions in Washington, D.C., notes that care management transitions are an area in which "the application of IT can improve quality, improve safety, and as a result can likely reduce costs." 

Good patient care requires an enormous amount of information to be conveyed, both within care teams and from setting to setting. Greenspun says. IT collaboration tools, can help coordinate teams, make clear where responsibilities lie, and help make sure that things don't get dropped and are not duplicated, 


He has observed increasing appreciation among provider organizations that transitions are actually a dangerous time for patients, which is being reflected in the changing nature of discharge summaries. "In the past, discharge summaries were focused on what happened, as opposed to here are the goals, here is what needs to be done and this is what has been done so far, and what information needs to be handed off to make the transition successful," he says. 

Greenspun notes that there is no single solution to optimizing care transitions. The ability to pull information together from different sources and make sense of it is important. One problem in the industry has been that there are a lot of technology solutions directed at a narrow piece of the puzzle, but they haven't been incorporated well into what Greenspun calls the "people-process-technology triad. You can solve one problem" he says, "like a great care coordination application. But if the data isn't there, or people can't access it, or it's not easy for the clinician to use it as part of their daily routine, it's not a real advance." 

Erica Drazen, managing director at the Global Institute for Emerging Healthcare Practices at Falls Church, Va.-based CSC, notes that most provider organizations did not choose care transitions as part of their Stage 1 meaningful use attestation. She says care management transitions will become a front-burner issue with the emergence of countable care and incentives to reduce readmissions. 

Where should hospitals initially focus their attention? Drazen says the smart money would focus on diagnoses. "The most costly patients, from a hospitals perspective, are more likely to need coordinated care, since they tend to go back into the hospital," she says. Medication lists also rank high: "If you have a medication list, at least you know what a patient s likely problem looks like," she says, adding that medication lists are a small, but a key, part of the continuity of care document. 


Pat Rutherford, R.N., vice president of the Institute for Healthcare Improvement, Cambridge, Mass., says there is a new awareness of the importance of care transitions compared to just five years ago, although there is still plenty of work to do in filling the patient engagement gap. 

She sees a need for better partnerships between IT solution vendors and quality improvement experts, to create system-wide solutions in an infrastructure that is often fragmented. Vendors need to sit down with clinicians who actually use the products, she says. 

Hospitals are in a position to assess a patient's comprehensive needs, but handoffs of patient information need to be designed to be useful for the end users, and not necessarily written from the hospitals perspective, she says. Some of the information that skilled nursing facilities, home healthcare agencies, and primary physician offices maintain may be the same, but other information may be different, she says. We will get better compliance on what patients need to do to care for themselves if we do a better job of conveying information in a simple, clear way," she says. She describes the hospitals role as a "pay it forward" dynamic of providing the information that the next provider of care needs, and what it can do to make that transfer of information successful. 

For that to happen, each caregiver needs information that is tailored to his or needs to make the best decision, Rutherford says. What s needed by each caregiver is a one-page summary of information that is relevant to their caregiving role. 

Rutherford believes that changes taking place under healthcare reform can improve care transitions by providing care that is customized to the patients' needs and preferences in every site of care, and then build connections to the whole continuum of care. "We need to be more patient-centered, and we need to think about care experiences over time,

Nurse-led interventions to reduce cardiac risk factors in adults.

Nurse-led interventions to reduce cardiac risk factors in adults.

* Nurse-led clinics may reduce cardiac risk factors in healthy adults, as well as those with established heart disease or known cardiac risk factors. (Grade A) 

* The use of nurse-led clinics is particularly supported in relation to blood pressure management, cholesterol reduction, dietary modification and increasing physical activity. (Grade A) 

* Long-term benefits of nurse interventions can be seen for some outcomes such as dietary modification and cholesterol levels, whereas others such as smoking cessation were inconclusive. Research needs to be undertaken to determine how best to support the nurse-led clinic with the aim of improve sustained improvement of health measures. (Grade A) 

* The cost-effectiveness of nurse interventions in relation to those provided by general practitioners or hospitals need to be established for each healthcare system. (Grade A) 

Information Source 

This Best Practice information sheet updates and supersedes the Joanna Briggs Institute (JBI) information sheet published in 20 05 (2) which is based upon a systematic review of 6randomised clinical trials. (3) Additional information has been derived from a systematic review published in 2007. (4) In total, this information is derived from 22 randomised controlled trials. Original references can be sourced from the systematic reviews. (3,4) 


In recent years there has been a general shift of focus in the management of chronic disease from the hospital to the community. An emerging area in community healthcare is the nurse-led clinic. Nurse-led clinics are seen to focus on health promotion and education, rather than treatment of illness and are well received by patients. There are also benefits for the practice nurse, as nurse-led clinics provide an opportunity for increased development of professional autonomy amongst nurse practitioners, particularly in areas of chronic disease, such as cancer therapies,continence management, wound care, smoking cessation and Coronary Heart Disease (CHD). 

Coronary Heart Disease is the major cause of illness and death in Western countries, an effect which is likely to increase as the population ages. Many of the included studies were conducted in the United Kingdom, where there is a high incidence of CHD; however, the care processes are no different to other Westernised countries and the outcomes are considered comparable. Individuals with established CHD are at the highest risk of experiencing further coronary events. Establishing and maintaining a healthy lifestyle may contribute significantly in reducing cardiovascular mortality in these individuals. In the current economic and political climate, optimising the management of the chronically sick is a prime concern. Providing nurse-led services to divert patients from busy hospital and general practice settings has been suggested as one way of maintaining quality care of patients with chronic illness, such as CHD. Conceptually, practice nurses have the potential to contribute to risk factor reduction as a result of their familiarity with the patient, availability for sustained consultation and the potential to apply interventions when patients are ready to initiate change rather than during a period of acute crisis. 


For the purposes of this information sheet the following definitions are used: 

General practice nurse--a registered or enrolled nurse who provides nursing care in a general practice environment, under some degree of supervision from their employing general practitioner

Coronary heart disease (CHD)--a term that covers a wide array of disorders, including diseases of thecardiac muscle and the vascular system supplying the heart, brain, and other vital organs. The most common manifestations are ischemic heart diseasecongestive heart failure, and stroke. 

Cardiac risks factors--health or lifestyle influences that increase the chances of CHD. Known risk factors include being overweight, smoking, elevated cholesterol levels, sedentary lifestyle and having a high intake of alcohol. 


The purpose of this information sheet is to present the best available evidence for nurse-led clinic interventions that reduce cardiac risk factors in healthy adults as well as those with knowncardiovascular disease

Quality of the research 

These reviews consist of Level A evidence in the form of 22 randomised controlled trials (RCTs). This information sheet represents a synthesis of the results of these trials. It should be noted though that several trials were limited by the presence of small sample sizes and relatively short follow-up periods. 

Types of Intervention 

The interventions of interest were those related to the broad area of practice, incorporated within nurse-led clinics for patients at risk of CHD. They included a range of strategies such as individualised health assessment, lifestyle counselling and advice giving, health education, follow-up, referral and motivational interviewing. More specific areas of focus were smoking cessation, reduction of alcohol consumption and weight loss programs. The effects of nurse interventions were most commonly compared with "usual care" however this was not always fully detailed. 

Outcome measures 

Primary outcomes of interest were; blood pressure, alcohol intake, cholesterol levels, diet, amount of physical activity undertaken, smoking status, body mass. Results of these outcomes are reported below. Secondary outcomes of interest included anxiety, depression and satisfaction with treatment. There is some evidence to suggest that patients with known CHD showed a significant reduction in self-reported symptoms of anxiety and depression following nurse-led education sessions and motivational interviews, compared with usual care. (2) 

Blood pressure 

Participants who received nurse-led guidance in the form of motivational interviews, consultations and an educational manual had reduced systolic and diastolic blood pressure after 18 weeks, regardless of their initial health status. Five trials (3 clinical and 2 in the general community) found significant reduction in blood pressure either between the intervention and control groups or from baseline to the 12-month follow-up. Prescription of antihypertensive drugs also decreased substantially during this time. Follow-up data at 18 months was provided by two studies which revealed no significant difference between mean systolic or diastolic blood pressure for the intervention groups compared with controls. These findings imply that the nurse interventions are effective over a 12 month period; however this benefit is no longer seen at 18 months. 

Alcohol intake 

The effect of nurse-led education sessions on alcohol intake was assessed in two studies and both found that participants--either with or without known cardiac risk factors- decreased their alcohol intake in response to nurse- led information sessions. This result was significant at 18 weeks but was not sustained at 12 months, 18 months or 4 years. 

Body Mass 

Studies that examined the body mass of overweight individuals reported a decrease in percentage body weight or body mass index (BMI), over a third of participants lost up to 5% (Counterweight study, 2005). It was unclear in most studies was about whether the weight loss was sustained long-term. 


Three studies demonstrated significant improvements in mean cholesterol levels at 3 months, 12 months and 4 years. One study noted that those with higher initial cholesterol levels showed larger decreases than those with lower starting levels. Potentially, this reflects the capacity for change in contributing factors such as dietary intake in this group. One study highlighted that a practice nurse-led group showed significant reductions in total cholesterol, high and low density lipoprotein concentrations compared to baseline at the end of a 6-month trial. Another study compared practice nurse advice to usual care. 80% compliance was achieved at the 12-month follow-up with the intervention group indicating mean reduction in serum cholesterol compared to the control group. This was accompanied by a fall in the percentage of food energy from both total and saturated fat. 


Four studies using either a self-report questionnaire, fat score or saturated fat intake showed general improvement in diet following nurse-led intervention. Two CHD-oriented studies reported significant improvements in diet. The Change of Heart study (2005) demonstrated greater decrease in fat intake of the intervention group compared to the control group. Two studies reported significantly lower saturated fat intake by the intervention group at 1 and 4 years, suggesting sustainable lifestyle changes. 

Physical activity 

Studies that examined the impact of nurse intervention on the level of physical activity revealed a general increase in the amount of self-reported physical activity being undertaken by participants. 

Counselling combined with nurse education and an education booklet led to an increase in walking distance covered. A high or low level of patient-nurse interactions had no effect on physical activity. 


The effectiveness of nurse-led interventions on smoking cessation is unclear and is complicated by self-reporting methods. One study reported a significant decline in cigarettes smoked per day in the nurse intervention group after 4 months (Change of Heart study). A decrease in the number of cigarettes smoked per day was maintained in the intervention group at one year, however it was no longer significantly different from controls. 

There were discrepancies between self-reported smoking status and laboratory results, i.e. participants in control and intervention groups continued to smoke despite claiming to have stopped. 


More recent research does not alter the recommendations published in 2005. The importance of nurse interventions in the management of coronary heart disease and risk factor reduction is recognised in terms of improved health outcomes for patients. However, the variation in outcome measures and inconsistent findings between some studies makes it difficult to draw firm conclusions. Improvement was demonstrated in the outcomes of anxiety and depression, quality of life, general health and lifestyle including dietary intake and physical activity. Beneficial effects attributable to nurse- led clinics were also identified for reduction in severity of angina, blood pressure, cholesterol levels, adherence to medication schedules, and lifestyle changes. Of these, only blood pressure, body mass and cholesterol levels were measured on the patient. All other outcomes were self-reported and should be interpreted with caution. It should be noted that reductions in blood pressure were reported at 12 but not 18 months, indicating that interventions are effective in the short and medium term. This trend of early and medium term success is also observed with reduction in body mass. Additional methods may need to be employed for there to be long term changes. Improvements in diet and cholesterol levels were observed up to 4 years after the intervention, showing that nurse-interventions can have long- term benefits on health care outcomes. The effectiveness of nurse-intervention on smoking cessation is unclear, there is some evidence to suggest that the number of cigarettes smoked decreased during the short term, however this was a small reduction which was not sustained past 12 months.

Educational interventions to raise men's awareness of bladder and bowel health.

Educational interventions to raise men's awareness of bladder and bowel health.

Urinary incontinence (UI) is an objectively demonstrable condition in which the involuntary loss of urine is a social or hygienic problem. Urinary incontinence is a common health problem that carries with it significant medical, psychosocial and economic burdens.(2) Faecal incontinence has been defined as the involuntary or inappropriate passing of liquid or solid stool and can also include the incontinence of flatus. Studies suggest that twice as many men suffer from faecal incontinence compared to urinary incontinence whilst more than three times as many women suffer from urinary incontinence compared to faecal incontinence.(2) The general consensus in the literature is that barriers exist for seeking help for those with incontinence, especially men. 


The purpose of this Best Practice Information Sheet is to present the best available evidence identified from a review assessing the effectiveness of educational interventions at raising men's awareness of bladder and bowel health, with the idea that raising awareness will lead to an increase in help-seeking behaviour. 

Types of Intervention 

The review considered any intervention, program or action that provided information, or attempted to raise awareness of men's bladder and bowel health. None of the included studies evaluated interventions to improve men's knowledge or management of bowel health, or to improve men's attendance at promotional events. 

Quality of the research 

The review identified 12 randomized and two quasi experimental studies and overall the quality of the included studies was moderate. Only two RCTs described their method of randomization and no trials reported using blinding. Two studies did not provide the measures of dispersion (no standard deviation), one study provided graphical data only and one presented no data whatsoever. 


Pelvic floor muscle exercises (PFME) for prostatic cancer 

Nine randomized controlled trials (RCTs) and two controlled trials examined the effectiveness of pelvic PFME on improving urinary incontinence in males ([greater than or equal to] 65 years) who have undergone prostatectomy. For participants with stress urinary incontinence, PFME may train the person to exert a well-timed, fast and strong voluntary pelvic floor muscle contraction just prior to an exertion. This contraction may clamp the urethra to increase intraurethral pressure and prevent urine leakage. For participants with urge urinary incontinence, it has been suggested PFME, conditions areflex inhibition of detrusor contraction, thus preventing involuntary contractions and urine leakage. 

Random effects meta analysis was performed with two RCTs with similar populations (men after prostatectomy), interventions (pelvic floor muscle training) and outcomes (urinary continence at 1, 3, 6 and 12 months). This analysis revealed that treatment with PFME resulted in statistically significant reductions in the number of incontinent participants at 3 months (RR= 0.35, 95%CI 0.25, 0.49), 6 months (RR= 0.313, 95%CI 0.06, 0.25), and 12 months (RR= 0.15, 95%CI 0.05, 0.42), of PFME when compared with controls who did not practice PFME. 

These findings were echoed in a RCT of older males ([greater than] 66 years, N= 58). The PFME group showed significantly more participants attaining continence compared with the no PFME group at week 1, 2 and 3 of treatment, but not at 4 weeks. 

Two RCTs examined the effectiveness of PFME in combination with biofeedback in men who had undergone radical prostatectomy and neither study reported any significant improvement in the number of incontinent episodes per 24 hours, or at reducing the number of grams of urine loss in a 24 hour period, when compared with the control groups. One RCT (n=24) randomised the subjects to either a biofeedback with pelvic floor muscle exercises group (45 minute sessions at 6, 7, 9, 11, and 16 weeks post-op) or a "no instruction" control group. PFME plus biofeedback was no more effective than the control in these patients for reducing the number of incontinent episodes per 24 hours, or at reducing the number of grams of urine loss in a 24 hour period. In the second RCT, (n=42) males afterradical retropubic prostatectomy for localised prostate cancer were randomized to receive either pelvic floor muscle exercises with biofeedback or to PFME with verbal feedback only. Results showed that although urine loss (measured by 1 hour pad tests) reduced significantly from baseline to 1, 2, 3 and 6 months for both groups, there was no significant difference between the two groups. 

In a RCT, 63 males four or more weeks after radical retropubic prostatectomy (mean age [greater than] 65 years) were randomised to either pelvic floor muscle exercises with intensive physiotherapy, PFME with electrical stimulation (ES), or PFME only provided by simple written and verbal instruction. While all groups showed significant reductions in urine loss (using the 24 hour pad test) at 12, 16 and 24 weeks compared to baseline, no significant differences were found between any group at any time point. 

In a similar RCT, 139 older males (mean age 65 years) who had undergone radical prostatectomy were randomized to one of three treatment groups: 

1 Pelvic floor muscle exercises plus intensive physiotherapy 

2 PFME plus electrical stimulation 

3 PFME plus ES plus biofeedback 

Again, significant improvements in the number of continent participants were seen at each time point for each treatment group, however, no significant differences were found between any of the treatment groups at any time point. 

In a RCT of 36 males with urinary incontinence after radical prostatectomy (mean age [greater than] 66 years) were randomized to treatment consisting of PFME or functional pelvic floor electrical stimulation (FES), or extracorporeal magnetic stimulation (ExMI) and followed up for 6 months. Using a 24 hour pad leakage test, there was little difference in the comparative effectiveness between the three treatment arms. There was significant reduction in the amount of urine leakage over time compared to the baseline (catheter removal) beginning at one month post-removal of the catheter. By 6 months urinary leakage was less than 10 grams in a 24 hour period compared with [greater than] 660grams 24 hours after catheter removal. 

Finally, in a quasi experimental study of 24 male prostatectomy patients (mean age 70.2 years) introduction of PFME resulted in 16 of 24 (67%) participants exhibiting at least a 50% improvement in the number of incontinence episodes. At 1 to 17 months follow-up, 11 participants who had initially shown improvement reported no change to their condition or further improvement. 

Post-micturition dribble 

Two RCTs attempted to address the use of educational interventions at reducing the symptoms of post-micturition dribble. In the first RCT, 44 men were randomized to receive either: 

a) counselling, 

b) training on urethral milking, or 

c) training in performing PFME. 

The authors found that both milking and pelvic muscle exercises were significantly more effective at reducing the amount of urine lost post-micturition than counselling. 

In the second RCT, 55 men with erectile dysfunction and post-micturition dribble were randomized to receive either advice on lifestyle changes (control) or PFME combined with biofeedback and lifestyle change advice (treatment). The results showed that after 3 months nearly all treatment recipients were free of post-micturition dribble (19 of 21) while only one third of control subjects were free (5 of 15) with a risk of having post-micturition dribble less than 20% of that of the control group (RR 0.14, 95% CI 0.04, 0.56). At 6 months however, both treatments were equally successful with no-one in the treatment and only 2 men in the control group still suffering post-micturition dribble. 

Lower urinary tract symptoms 

An RCT evaluated the effectiveness of lifestyle and behavioural education sessions on men suffering from uncomplicated lower urinary tract symptoms (LUTS). The primary outcome was the number of treatment failures defined as evidence of urinary retention, a rise of 3 points or more on theinternational prostate symptom score, the need for drugs or a surgical intervention to control LUTS. When compared with a standard care control group, participants provided with education had significantly fewer treatment failures at every time point (3, 6 and 12 months) with a reduced risk of failure of over 60% (RR 0.38, 95%CI 0.24, 0.58 at 12 months). A decrease in the number of treatment failures were reported over time for each group. 

Evidence based guidelines for management of urinary and/or faecal incontinence 

One quasi experimental study examined the effectiveness of consensus guidelines designed for the management of continence by primary health care teams placed in an urban general practice. A random sample of patients of this general practice were mailed a questionnaire to determine their continence status (N=1503). Those that were identified as incontinent and agreed to follow-up (174 patients, 42 males) were encouraged to attend the practice where GP's could institute best practice treatment according to the guidelines. Only 4 males actually sought help and 3 or 4 (number unclear from the text) still considered their incontinence to be a problem after the intervention. Therefore, a conclusion as to the effectiveness of these guidelines in males cannot be ascertained, due to lack of detail in the study report. 

Music interventions for dental anxiety in paediatric and adult patients.

Music interventions for dental anxiety in paediatric and adult patients.

Dental anxiety has been identified as a significant and common problem in both children and adults and is considered an obstacle in the provision of quality dental care by dental care providers. It is reported that one in six adults suffer from some form of dental anxiety and in children the prevalence ranges between 5.7% and 19.5%. (2) Dental anxiety denotes a state of apprehension that something dreadful is going to happen in relation to dental treatment and it is coupled with a sense of losing control. (2) Patients with dental anxiety tend to neglect dental care which poses a problem for both dentists and patients. A dentist-patient relationship dominated by severe patient anxiety may lead tomisdiagnosis and inappropriate treatment. (2) Treatment of dental anxiety and choosing the right method of managing this disorder is not always easy. Effective treatment options may include; an explanation of the treatment procedure, pharmacological strategies involving the use of benzodiazepines and antidepressants, biofeedback, hypnosis and behavioural interventions. (2) Music offers an alternate treatment option which has been used in different medical fields to meet physiological, psychological, and spiritual needs of patients. The anxiolytic effects of music have been studied in a variety of medical patients, including surgical, cardiac, and oncology patients. (2) People of any age may benefit from a music therapy programme regardless of musical skill or background. Several measures and scales have been developed to classify dentally anxious patients and to assess their level of anxiety for prevalence, aetiology and treatment studies. (2) Music is believed to reduce dental anxiety by either having a relaxing or distracting effect (or both) that in turn reduces the activity of the neuro-endocrine and sympathetic nervous systems. (2) 


For the purposes of this information sheet the following definitions were used (2): 

Dental anxiety is defined as an abnormal fear or dread of visiting the dentist for preventive care or therapy and unwarranted anxiety over dental procedures. 

Active music therapy is the planned and creative use of music by a music therapist to attain and maintain health and wellbeing. 

Passive music listening is the passive listening to pre-recorded music offered by healthcare professionals without the involvement of music therapist. 


The purpose of this Best Practice Information Sheet is to present the best available evidence on the effectiveness of music interventions on dental anxiety in paediatric and adult patients. 

Types of Intervention 

The interventions of interest were active music therapy and passive music listening throughout the dental procedure. The former involves a music therapist and interactive communication; the latter involves listening to music or passive listening to pre-recorded music offered by dental personnel. The type of music may vary (e.g., folk, contemporary, classical, lullaby). Studies including a combination of interventions where the direct effect of the music intervention cannot be determined (for e.g. relaxation therapy combined with music or pharmacological therapy with music) were excluded. Comparators included talking, placebo (headphones without music), relaxation techniques (such as progressive muscular relaxation, paced breathing etc) and pharmacological techniques (such as sedation with nitrous oxide and other anxiolytic drugs like diazepam, midazolam etc). 

Quality of the research 

Seven studies were included in the review, two RCT, four quasi-randomised, and one quasi-experimental study. (2) Four studies that claimed to be randomised failed to report the method of random allocation, hence these studies were considered as quasi-randomised studies. The approaches used by studies reporting method of randomisation were: random number table used for block random assignment and electronic spread sheet of random numbers. Only two studies attempted to determine sample size by using power analysis. 


Paediatric patients 

Upbeat music distraction vs relaxing music distraction vs no music control 

A quasi experimental study investigated the effects of music distraction on anxiety and behavior in 45 patients 4 to 6 years of age Columbus, Ohio (USA). Patients were divided into three equal groups: upbeat music distraction, relaxing music distraction and no music control. The upbeat music consisted of age-appropriate folk music songs (A Child's Celebration of Folk Music by various artists, 1996). The relaxing music was slow, 

lulling instrumental music (In the Enchanted Garden by Kevin Kern, 1996). Behaviour management techniques of tell-show-do and voice control were used, if necessary, in a conventional manner. There was no significant difference in Corah anxiety scores at either visit 1 or visit 2 among the three groups. Visit 1 was a baseline session with no music distraction or headphones used. Visit 2 was scheduled 1-2 weeks after visit 1. Children in the two music groups wore headphones whilst the control group wore headphone without music played. Measurements showed that there was no significant difference in self-reported anxiety among the three groups at visit 1 or visit 2. In addition, there was no statistically significant difference between pre- and post-operative scores in any of the groups. 

Instrumental music vs nursery rhymes vs control 

A quasi randomised controlled trial investigated the effect of music distraction in managing anxious paediatric patients and in addition compared two different types of music to ascertain the type of music most helpful for reduction of anxiety. Forty children aged between 4 and 8 years with no previous dental experience were included in the study conducted in India. Children were randomly divided into two groups initially: control group (group A) and music group. Music group was further equally divided into two groups: instrumental music group (group B) and nursery rhymes music group (group C). Patients chose their music type and listened to the music through headphones throughout the treatment during all the visits. There was statistically significant difference between the anxiety ratings among instrumental music group and nursery rhyme group, with anxiety being more in the later group. The control group showed higher mean pulse rate compared to both the music groups; however the differences were not statistically significant. There was a statistically significant difference between the mean pulse rate of the instrumental music group and nursery rhyme group, with anxiety being more in the later. 

Adult patients 

Relaxation vs music vs music with volume control vs control 

Eighty college students (40 males) who required a minimum of class II amalgam restorations were recruited for a quasi randomised controlled trial. The setting was a dental emergency school clinic in the USA. All patients were randomly assigned to one of the four groups. The groups included relaxation, music, music with volume control (second music group) and control group (treatment not specified). Relaxation involved presentation of tape-recorded relaxation instructions through ear phones worn by the patient. Music intervention included recorded music through earphones throughout the dental procedure and patient had a choice of eight musical programs ranging from classical to popular. Patients had the option to set the volume in the third group (second music group). There was a significant difference in level of anxiety between the visits for control and relaxation groups when each group was tested individually. The decrease in anxiety was not significant for both the music groups. In the group-by anxiety-by-visit analysis, the results indicated that only the high-anxiety control group and the high-anxiety relaxation group showed statistically significant decreases in rated discomfort to the second visit. A repeated measures analysis of relaxation and distraction measures by groups showed that there were significant differences in the relaxation group and the second music group. 

Music vs nitrous oxide/oxygen 

A quasi randomised controlled trial investigated the effects of music on reducing patient's fear and anxiety. Eighty male and female patients (between 18 and 65 years of age), from Utah (USA) were randomly assigned in one of eight categories. Patients in the music group had a choice of five different types of music (classical, Broadway hits, new age, country and western, and light contemporary hits). A statistically significant reduction in the level of stress in female patients was observed with music listening alone, in contrast to male patients where there was no statistically significant difference. 

Music (favourite songs from a music list) vs control 

A quasi randomised controlled trial evaluated the efficacy of musical intervention to decrease anxiety and change of vital signs in participants who underwent surgical extraction of an impacted mandibular third molar (IMTM) at the Seoul National University Dental Hospital (Korea). Participants were randomly assigned to a music treated group and a control group. Patients in the music group were asked to select at least 10 of their favourite songs from a prepared music list that included classical music, pop songs, folk songs, hymns and Korean style country songs. Throughout the dental procedure, patients in the music group had the option of controlling the volume of the music using a remote control. Patient vital signs were measured upon arrival in the operating room (baseline) and throughout the surgical procedure (beginning from local anesthetic injection to completion and suturing). Baseline vital sign measurements were similar in both the groups. The mean systolic blood pressure and diastolic blood pressure varied significantly with surgical stage for both groups. There were significant differences between music treatment group and control group with respect to heart rate and respiratory rate changes from baseline. The study showed that patients in the music treatment group had significantly lower levels of intra-operative anxiety than patients in the control group. 

Music (soothing piano music) vs control 

One randomised controlled trial investigated the effect of music on anxiety during root canal treatment. Forty four subjects between 20 and 65 years of age were randomised to music and control group. Participants in the music group were exposed to a variety of soothing piano music through headphones with adjusted volume. Participants in the control group underwent the same procedure without the evaluation of music preference and a CD of silence played during the procedure. There was a statistically significant difference in state anxiety scores between the music group and control group, anxiety levels being higher in the later group. 

Brief relaxation vs music distraction vs control 

randomized controlled trial tested the hypothesis that brief relaxation (BR) was effective and superior to music distraction (MD) for the treatment of dental anxiety. Adult participants from a rural area in Germany were randomised to the BR, MD or control groups. Participants in control group did not receive any treatment for dental anxiety. There was a statistically significant decrease in anxiety after dental treatment in all the three groups, with the greatest decrease in the BR group. There was a relatively small decrease in anxiety after dental treatment in the control group whilst the MD group presented a statistically significant reduction in state anxiety compared to the control group. The reduction in anxiety following BR was greater than that in the control and MD groups. Stratification of anxiety levels revealed that BR was effective in alleviating state anxiety throughout all levels of dental anxiety, demonstrating the largest effect in highly anxious participants. Participants in the MD group showed reduced anxiety in the moderately anxious subgroup. 

Adolescent care standards and state CHIP efforts.

Adolescent care standards and state CHIP efforts.

Although widely thought of as a health insurance program for younger children, the State Children's Health Insurance Program (CHIP) also has enormous potential to expand insurance coverage, including coverage of reproductive health guidance and services, to millions of uninsured teenagers. The extent to which CHIP meets this potential will largely be determined by the individual states, which have considerable discretion in designing their own efforts and benefit packages. For guidance in making critical coverage decisions, states can look to several comprehensive guidelines for adolescent health care, including reproductive health services, developed in recent years. 

Congress established the State Children's Health Insurance Program (CHIP) in 1997 in response to data indicating that there were over 10 million uninsured children in the United States that year--including 2.7 million teenagers between the ages of 13 and 18 (1.3 million females and 1.4 million males). With nearly $40 billion in federal funds available to them over 10 years, the states are charged with establishing CHIP programs, which may enroll children under age 19 in families with incomes up to 200% of the federal poverty level. The Health Care Financing Administration (HCFA), the federal agency that administers CHIP, reports that two million children were enrolled nationwide as of September 30, 1999. 

According to the federal CHIP statute, a state may design its CHIP program in one of three ways: by expanding its Medicaid program, by creating or expanding a state-designed program not based on Medicaid or by using a combination of the two approaches. A 1999 review by The Alan Guttmacher Institute (AGI) of the initial state plans submitted to HCFA found that 21 states and theDistrict of Columbia had opted to expand their Medicaid program, 16 states were developing an entirely separate program, and 13 states intended to take a combination approach. 

In the states choosing to expand their Medicaid program, CHIP enrollees are regular Medicaid enrollees; as such, they are entitled to the full range of Medicaid-covered services, including routinegynecologic examinations, Pap tests, diagnosis and treatment of sexually transmitted diseases (STDs) as well as family planning services and supplies. (The federal Medicaid statute specifically mandates coverage of family planning services for "minors who can be considered to be sexually active.") 

In contrast, the states choosing to design programs of their own have wide latitude in crafting a benefit package. The CHIP statute itself requires coverage of only such basic services as physician and hospital care, laboratory and X-ray services, well-child care and immunizations. According to the AGI review, of the 29 approved state plans that had some state-designed component, 16 specifically indicated that family planning services and supplies would be covered, while most of the remaining plans indicated that the general category "prenatal care and pre-pregnancy family planning services" would be covered. 

Teens' Reproductive Health Needs 

Teens need a range of educational and medical services related to reproductive health. Half of all U.S. teens are sexually experienced. While sexual activity is rare among younger teens, it is common in the later teenage years; by age 19, over three-fourths of females and 85% of males have had intercourse. Yet, teens are less likely than older women to report consistent use of effective contraceptive methods. In addition, sexually active teens younger than 18 are less likely to use any method of contraception, compared with older women. 

Contraceptive use is critical for sexually active teens to avoid unintended pregnancy and to protect themselves against STDs. A sexually active teenager who does not practice contraception has a 90% chance of becoming pregnant within one year. In fact, every year, some 900,000 American teens between the ages of 15 and 19 become pregnant, giving the United States one of the highestteenage pregnancy rates in the developed world. 

The United States also has among the highest teen STD rates in the developed world. Each year, three million teens--about one in four sexually experienced teens--acquire an STD, which can compromise their ability to have children later in life or lead to life-threatening health problems, such as cancer or HIV infection. For example, recent studies indicate that up to 1030% of sexually active teenage women tested for STDs are infected with chlamydia, which, if left untreated, can lead topelvic inflammatory diseaseectopic pregnancy and infertility. Additionally, teens have higher rates ofgonorrhea than women older than 20, and some studies have found that up to 15% of sexually active teenage women are infected with human papillomavirus (HPV), many with a strain of the virus linked to cervical cancer

Nonetheless, there are some disturbing indications that teenagers may not always be getting the full range of reproductive health care services they need. According to a study in the July 1999 issue of Pediatrics, only half of all physicians reported that they provided any counseling or education in their encounters with adolescents; fewer than 3% reported providing counseling or education on STDs or HIV. According to the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, only 15% of adolescent boys and 26% of adolescent girls reported that their provider had discussed pregnancy prevention with them. Similarly, only 24% of boys and 28% of girls reported that their doctor had discussed how to prevent STDs or HIV. And a study in the December 15, 1999, issue of the Journal of the American Medical Association reported that adolescents who are sexually active are more likely than other teens to forgo important health care, such as an annual physical exam. The study found that 25% of sexually active teens had forgone care, compared with only 15% of teens who are not sexually active. 

Care Guidelines Remarkably Consistent 

For guidance in making important decisions about the coverage for adolescents in their CHIP program, state policymakers may look to several widely accepted guidelines of care for preventive services to teens that have been developed by major health organizations. The three most comprehensive efforts are Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, which was sponsored by the Department of Health and Human Services; Guidelines for Adolescent Preventive Services (GAPS), which was developed by the American Medical Association; and Primary and Preventive Health Care for Female Adolescents, which was published by theAmerican College of Obstetricians and Gynecologists (ACOG). These national guidelines strongly emphasize that comprehensive reproductive health services for teens, including both health guidance and medical care, are an integral component of preventive health services for this population. In fact, despite subtle differences, these recommendations, which are summarized below, are remarkably consistent (see chart). 

* Routine, preventive service visits 

Routine visits are the mainstay of comprehensive and coordinated preventive care for teens. Health Care for Female Adolescents recommends that the initial visit for health guidance, screening and preventive care take place between the ages of 13 and 15. This initial visit should be followed by annual preventive health visits. The American Medical Association's GAPS recommends that all teens between the ages of 11 and 21 receive annual, routine visits, including three complete physical examinations--one each during early (11-14), middle (15-17) and late (18-21) adolescence. 

All three sets of guidelines stress the importance of integrating medical care with education and counseling on responsible sexual decision-making. Annual preventive visits that promote routine and predictable screening, counseling and intervention are vital to this integrated approach. Since participation in risky behaviors can begin at any age, regular visits provide the opportunity to identify teens who have recently initiated, or are considering engaging in, such behaviors. They also offer an opportunity to identify teens who have recently become sexually active and to provide them with information concerning unintended pregnancy and STD prevention. 

The various guidelines recommend that all teens should be screened during routine, preventive visits to determine their sexual history and practices. A comprehensive sexual history can be used to identify risk and evaluate the need for services as well as additional counseling and education. GAPS recommends that sexually active teens be asked about "their use and motivation to use condoms and contraceptive methods, their sexual orientation, the number of sexual partners they have had in the past six months, if they exchanged sex for money or drugs, and their history of prior pregnancy or STDs. Adolescents at risk for pregnancy, STDs (including HIV), or sexual exploitation should be counseled on how to reduce this risk." GAPS adds that both teens and their parents and other adult caregivers should receive guidance on the use of "tobacco products, alcohol and other drugs" in conjunction with sexual activity. 

* Cancer screening 

The guidelines all recommend that sexually active female teens receive a Pap test annually to screen for cervical cancer. In addition, GAPS and Health Care for Female Adolescents recommend that females 18 or older receive annual Pap tests, regardless of whether they are sexually active. 

Bright Futures also recommends that instruction in breast and testicular self-examination be a part of routine physical examinations; the other practice guidelines do not address the issue. 

* STD/HIV screening 

The various guidelines also recommend that all sexually active teens be screened for gonorrhea and chlamydia. Health Care for Female Adolescents and Bright Futures recommend that these tests be performed annually, while GAPS suggests that the frequency of the screening should depend on the individual's sexual history. 

For teens at risk for HIV, the guidelines recommend that testing be confidential and that it occur only after the teen gives informed consent and in conjunction with pre-test and posttest counseling. 

GAPS makes additional recommendations regarding follow-up for positive STD tests: Positive results should be followed by additional tests, as appropriate to make a definitive diagnosis, and a treatment plan should be instituted and the use of condoms encouraged. 

* Health guidance on sexual development 

The guidelines all recommend that as a part of routine health visits, teens receive health guidance--information, counseling and anticipatory guidance--about puberty and sexual development. In the context of health guidance on sexual development, Bright Futures suggests that health professionals ask young adolescents such questions as "Has anyone talked with you about what to expect as your body develops? Do you think you are developing pretty much like the rest of your friends? Have you started your period? Is it regular?" Health professionals can use the answers to these queries to provide information and counseling about sexual development appropriate to the individual patient. 

Both Health Care for Female Adolescents and GAPS additionally recommend that parents or other adult caregivers be given periodic guidance regarding sexual development. 

* Health guidance on responsible sexual behavior and decision-making The various guidelines recommend that all teens receive information and counseling--as part of routine, preventive service visits--about sexual decision-making, including information about abstinence, contraceptive methods, and STD transmission and prevention. According to all the major guidelines, teens should be given information on the importance of pregnancy and STD prevention, the role of abstinence as an effective way to prevent unintended pregnancy and STDs, ways to prevent HIV transmission and basic facts about protection from sexual exploitation. Adolescents should also be given counseling to reinforce responsible sexual behavior, both among those who are not currently sexually active and among those using birth control and condoms effectively. 

Health Care for Female Adolescents specifically urges that teens be informed that the most effective protection against unintended pregnancy and STDs, other than abstinence, is a combination of latex condoms and hormonal methods of contraception. GAPS recommends that all adolescents should receive annual counseling on responsible sexual behaviors, including abstinence. "Latex condoms to prevent STDs, including HIV infection, and appropriate methods of birth control should be made available, as should instructions on how to use them effectively." 

Health Care for Female Adolescents specifically recommends that teens be counseled aboutemergency contraception

Bright Futures suggests that health professionals question teens about the information they have learned from their family, friends, school and other sources, and supplement that information in the course of responding to their specific questions, problems or concerns. Bright Futures also suggests that the handouts that health professionals give adolescents to review at home should include, among other things, statements such as "Recognize that sexual feelings are normal, but having sex should be a well-thought-out decision. Delay having sex until you are mature enough to assume responsibility for sexual relations. If you are sexually active, discuss contraceptive methods and STD prevention with the health professional and your partner. Learn about and practice safer sex." 

The Critical Role of Confidentiality 

While routine guidance and care may play a vital role in preventing myriad serious health and social consequences, teens face substantial barriers to accessing care, including, among other things, deep-seated concerns about confidentiality. These concerns may prevent teens from seeking care in a timely fashion, or at all. As a result, the various guidelines stress the importance of confidentiality as a basic underpinning of the relationship between teenage patients and their health care providers. For some longstanding patients, this can mean recasting an ongoing relationship that had included parents as equal partners. For newer patients, it may mean developing a relationship that is built from the start on the premise of confidentiality. According to the various guidelines, health professionals should establish office policies regarding confidential care for teenagers, and both teens and their parents should be informed of these policies from the outset. According to Health Care for Female Adolescents, confidentiality is frequently identified as a major obstacle to the delivery of care to teens. As a result, the guidelines recommend that rather than wait until a problem arises, physicians should initiate discussion of the subject with both the teenager and her parents, and at the same time stress the importance of open communication among all parties. 

Serving Teens 

Major Guidelines for Reproductive Health Services to Teenagers 

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents was developed by a special commission and a set of expert panels sponsored by the Health Resources and Services Administration and the Health Care Financing Administration of the Department of Health and Human Services. The second edition of the report, released in 2000, includes recommendations for preventive services from infancy through adolescence. 

Guidelines for Adolescent Preventive Services (GAPS) was de the American Medical Association and released in 1992. GAPS was written with the assistance of a national scientific advisory board, which consisted of experts in medicine, social and behavioral science and health insurance. 

Primary and Preventive Health Care for Female Adolescents by the American College of Obstetricians and Gynecologists (ACOG) in November 1999. The guidelines were developed under the direction of the Committee on Adolescent Health Care and were based in part on the American Medical Association's GAPS, which itself was developed with representation from ACOG.
                     Bright Futures:       Guidelines for
                     Guidelines for        Adolescent
                     Health                Preventive
                     Supervision of        Services
                     Infants, Children,    (GAPS)
                     and Adolescents
Developed by         Department of         American
                     Health and            Medical
                     Human Services        Association

Target Ages          11-21 years           11-21 years
Periodicity of       Annual                Annual

Suggested Components of Health Guidance

Sexual               X                     X
Breast/Testicular    X
Unintended           X                     X
STD Prevention       X                     X


Pap Test             Sexually active       Sexually active
                     teens, annually       or age 18,

STD Screening

Gonorrhea            Sexually active       Sexually active
                     teens, annually       teens *
Chlamydia            Sexually active       Sexually active
                     teens, annually       teens *
Syphilis             High-risk teens       High-risk
Human                Sexually active       Sexually active
Papillomavirus       teens, annually       teens *
HIV                  High-risk teens       High-risk

                     Primary and
                     Preventive Health
                     Care for Female
Developed by         American College
                     of Obstetricians
Target Ages          13-20 years
Periodicity of       Annual

Suggested Components of Health Guidance

Sexual               X
Unintended           X
STD Prevention       X


Pap Test             Sexually active
                     teens or age 18,

STD Screening

Gonorrhea            Sexually active
                     teens, annually
Chlamydia            Sexually active
                     teens, annually
Syphilis             High-risk teens
Human                Sexually active
Papillomavirus       teens, annually
HIV                  High-risk teens

* Frequency of screening depends on the individual's sexual practices
and history of STDs.

Note: High risk is generally defined as a history of STDs, multiple
sexual partners, having had a sexual partner who is at risk of STDs,
history of having sex in exchange for money or drugs. Most of the
standards also include living in a geographic area with a high
incidence of syphilis as a risk factor for syphilis and a history of
intravenous drug use or having had a blood transfusion before 1985 as
a risk factor for HIV.