The aim of this study was to prioritize hospital admissions for ambulatory care sensitive conditions (ACSCs) and interventions for future research and implementation.

Initiatives aimed at reducing hospital admission need to be targeted at those patients who could avoid admission to hospital, either by prevention, earlier detection and treatment, or by the provision of alternative types of care. Admissions for ACSCs should ideally be prevented by care provided outside hospital.

The study used a modified Delphi method to elicit the views of an expert panel. The Delphi process comprised two rounds and used a Web-based questionnaire. Participants were purposively sampled and comprised primary and community care clinicians, emergency clinicians and commissioning managers. Quantitative data were analysed to produce descriptive statistics. Qualitative data were analysed using content analysis.

A total of 36 participants responded to both rounds of the Delphi survey. The condition given top priority was dementia, not currently a widely recognized ACSC or a national priority. The proportion of admissions that could be avoided by provision of care outside hospital was the most important factor in deciding which conditions to prioritize. Access to rapid response nursing and social care at home, intermediate care beds and mental health crisis teams were identified as key interventions to reduce admissions. Analysis of qualitative data showed several themes underlying clinical decisions to admit potentially avoidable admissions.

In conclusion, the conditions selected by the panel for prioritization showed some concordance with the National Health Services’ priorities in this area; but the condition given top priority by the panel – dementia – is not currently a national priority. The panel showed a high degree of consensus around interventions that might lower the rate of avoidable admissions. The highest rated interventions involve the direct delivery of rapid access care in the community.

An increasing number of blood tests are being performed in primary care. Informing patients of results takes up a considerable proportion of practice-staff time. The use of new technologies may be more time-efficient for staff but little is known about the acceptability to patients.

To determine patient attitudes towards the use of three technologies – short message service (SMS), webpage and e-mail – for the delivery of laboratory results.

Structured interview.

Two hundred patients were interviewed in two general practices in Lothian, Scotland. Satisfaction with current methods and preferred methods of obtaining test-results were assessed. Patients were asked about their current access to different technologies and their favourability to using such technologies for receiving results and their views on appropriate content and information security. Results were analyzed by age, sex and educational attainment using χ2 test.

A total of 79.5% of patients had mobile phones, 53% used SMS, 46.5% had internet, and 37.5% used e-mail. E-mail, SMS and webpage was the favoured delivery system for 53.3%, 37.1% and 33.3%, respectively.

Patients were favourable towards e-mail but not SMS or a webpage. The main concern over the three technologies was information security. New technology may be useful for delivering results but patients will have to be persuaded that any such system is reliable and secure.

This study explored health visitors’ perception of their role in the universal childhood immunisation programme with particular emphasis on influencing factors and communication strategies.

The majority of parents’ consent to immunisation, but some find decision-making in this area difficult and have unmet information needs. In the United Kingdom, health visitors routinely provide immunisation information for parents, whereas general practitioners (GPs) and practice nurses tend to administer vaccines and respond to parents/carers’ questions. Research has investigated health professionals’ views and knowledge about immunisation, but less is understood about health visitors’ role and how they communicate with parents.

Following the Local Research Ethics and Research Governance permissions, all health visitors (n = 120) working in one county in the United Kingdom were invited to participate in the study. Semistructured interviews (n = 22) were undertaken using a prompt guide. The interviews were transcribed verbatim. Thematic analysis using an iterative approach was used to explore the data facilitated by NVIVO™ software.

Five themes emerged from the interviews. These were health visitors’ professional role; identity and perceived barriers and communication strategies, parents’ right to choose, confidence in measles, mumps, and rubella (MMR) vaccination and communicating with migrant families about immunisation. There were differences between the health visitors in their perceptions of their roles, skills and knowledge and communication strategies. Health visitors perceived that GPs and practice nurses took a paternalistic approach to the provision of immunisation information, while they used a parental decision-making model. Health visitors reported a loss of professional confidence following the MMR crisis.

Given the evidence that some parents find it difficult to gain the information they need about immunisation and health visitors’ acknowledgement that their usual communication models were not effective during the MMR crisis, we feel specific communication skills training is needed to enable health professionals to provide parents with appropriate decision support.

Osteoporosis is a chronic and progressive disease leading to gradual deterioration of skeletal tissue, which predisposes the sufferer to an increased risk of fracture, deformity, disability and even premature death. The growth of this ‘silent epidemic’ is projected to escalate worldwide with the changing demographics of an ageing population. Recent reviews have highlighted the frequency of missed opportunities for secondary prevention following a fracture, though these reported on practice in the mid-1990s when pharmacologic approaches to fracture reduction were in transition.

This review examines the current body of literature regarding the investigation of osteoporosis and prescribing of secondary bone prevention medication in older patients following fragility fractures.

A standard Boolean search framework was used to find all pertinent studies on the literature review question. A further set of results was obtained using a ‘snowballing’ technique by pursuing references of the initial studies and reviews found. As the aim was to determine if there have been changes in prescription rates in elderly patients in the light of new guidelines, studies were excluded if they had featured in recent systematic reviews.

The consistently low intervention rates reported in all included studies provide evidence that elderly individuals who experience fragility fractures are still not receiving adequate investigation or treatment for osteoporosis. Furthermore, this review has identified the potential for future research to describe the true extent of this problem in the UK.

Depression, isolation, low self-esteem, and lack of hope are just a few of the characteristics evident in adolescents involved in bullying. The aims of this study are as follows: to examine the association between involvement in school bullying and depressive symptoms and suicide ideation among victims, bully victims, and those uninvolved; to investigate the effects of vulnerability factors on depression and suicide ideation among subjects aged 17 involved in school bullying.

A self-reported school-based survey was completed by 290 secondary school students aged 17 years, attending the third grade, coming from 15 different classes of secondary schools in the Tuzla (coming from each municipality in the Tuzla Canton), 2007. Using peer nominations, three groups were established: victims, bully victims, and uninvolved participants as control group subjects. Data were obtained using a self-rated questionnaire on bullying, Beck inventory to identify depression and suicide ideations, and state-trait anxiety scales to assess anxiety state/trait among examinees. Data analysis was performed using SPSS version 12.0.

There was an increased prevalence of depression (29.0% versus 8.8%) and suicidal ideation (16.1% versus 3.5%) in adolescents who have been victims in relationships to respondents who were uninvolved subjects. There was an increased prevalence of depression (17.5% versus 8.8%) and suicidal ideation (15.8.1% versus 3.5%) in adolescents who have been bully victims in relationships to respondents who were uninvolved subjects too. Adolescents who are victims and those who are bully victims are more likely to have suicide ideation compared to uninvolved subjects. Discontent with financial situation is a vulnerability factor associated with elevated levels of depression in victims.

In evaluations of students involved in bullying behavior, it is important to assess depression and suicide ideation.

To explore changes in self-reported familiarity and use of guidelines dealing with cardiovascular risks (hypertension, dyslipidemia, adult obesity and smoking cessation) and general attitudes towards clinical guidelines before and after implementation programme, as well as the association of guideline training attendance and attitudes towards and use of guidelines.

The current care guidelines provide a useful tool in the management of cardiovascular risk factors. Evidence-based care and guideline use have a shorter tradition among nurses than among physicians.

A self-administered questionnaire was sent to all primary health care nurses and physicians in Päijät-Häme Health and Social Care District, an area of 210 000 inhabitants in Southern Finland, before and after the guideline implementation programme VALTIT.

Main outcome measures were self-reported familiarity with and use of guidelines on cardiovascular risks and items measuring attitudes towards clinical guidelines.

Among nurses, the reported familiarity with all the guidelines increased, but increase in use occurred only in respect of the dyslipidemia guideline. Among nurses, there was an association between participation in guideline training and guideline use. Physicians’ reported familiarity with and use of the adult obesity guideline increased during the study period. The proportion of nurses and physicians who reported that they had been asked to use the guidelines increased. Perceptions concerning the readiness to adopt the guidelines changed positively among nurses and were more positive among those attending at least one training event.

Results are encouraging regarding familiarity with guidelines. Regarding usage our results suggest that a two-year programme might not be enough to alter the deep-rooted practices and attitudes concerning lifestyle change related guidelines. The challenge lies in multi-professional implementation of guidelines on cardiovascular risks with special emphasis on lifestyle change as a treatment option.

The article seeks to provide evidence of developments in relation to the extent and type of information sharing between primary care trusts (PCTs) and other settings involved in the assessment and provision of services for older people with health and social care needs following the introduction of the Single Assessment Process (SAP) in England.

Poor communication between health and social care agencies with regard to individual service users has been an issue of concern internationally for many years. The SAP was introduced in 2001 in order to address some of the shortcomings in health and social care assessments of older people evident in the research and policy literature. An important element of this new procedure was the development of systems and practices to improve information sharing between agencies and settings.

The data were derived from a national cross sectional postal survey of SAP lead officers, responsible for implementation of the policy in geographical localities. Questions reflected the policy guidance issued by government. Data were analyzed using SPSS 14.

A response rate of 82% was achieved. Agreements regarding the transfer of information were more developed between PCTs and local authorities than with other agencies and settings. Some key elements of the SAP, as defined by the guidance, were not found to be in routine use. Traditional methods of information sharing were far more in evidence than were electronic approaches. Nonetheless, the SAP appears to offer a useful framework for improving inter-agency communication, an issue of perennial concern.

This study aims to describe and reflect upon how a sample of nurses, parents and young people experience consultations at local clinics and school health services. Central to the concept of health promotion is ensuring that focus is on the empowerment of clients through dialogue and participation. This study aims to explore public health nursing consultations with this in mind.

Norwegian public health nurses are in contact with almost all families at the child health clinic. They meet children and young people at school health services and youth clinics; putting them in an important position to promote health and prevent illnesses.

Participant observations and in-depth interviews are the methods chosen. The data were analysed using qualitative content analysis.

The study shows that good relationships are not only sustained by pleasantness but also by honesty and directness, provided that the relationship is based on trust and sincerity. Continuity and trust in services seem paramount to the service users’ satisfaction. Service users were not always able to put the reason for their appreciation into words, just as the nurses had difficulty verbalising their strategies. Words often fall short when attempts are made to capture the essence of caring, trust and other life phenomena. Openness on agenda and focus on feedback from service users are important in order to ensure empowering services. Further studies should address the interconnectedness of the service and the subtleties of public health nursing consultations.

To assess current primary care childhood obesity prevention activity and experiences of general practitioners (GPs) and practice nurses in delivering the ‘Mealtime Magic’ brief intervention. To determine the acceptability of the brief intervention and reported impact upon confidence and behaviour of parents.

A gap persists in the evidence base regarding brief childhood obesity prevention interventions in primary care, where good opportunities for primary prevention work lie.

A quantitative and qualitative evaluation design, without control group, with post-intervention evaluation of parental outcomes and ‘before and after’ evaluation of healthcare professional perspectives was employed, using questionnaires. Five primary care practices in Worcestershire, England took part: six GPs, seven practice nurses (11 females and two males). 110 of 223 parents receiving the intervention completed follow-up measures (107 females, two males and one gender unknown; 106 White British). The intervention involved providing the ‘Mealtime Magic’ leaflet regarding childhood healthy eating behaviours, with verbal reinforcement of three main messages, to all parents with children aged five years and younger presenting to primary care over a six-week period. Staff received a 30-minute training session.

Twelve of 13 health professionals ranked childhood obesity of importance relative to other priorities. Secondary prevention activities were undertaken more frequently than primary prevention. All professionals found the intervention easy to deliver; 12 of 13 stated they would use the leaflet in the future. Reported professional confidence in knowledge of evidence-based healthy eating behaviour messages increased following intervention delivery. Resource barriers and perceived parental sensitivity with subject were reported. Ninety two percent (100/109) of parents stated the leaflet was helpful. Up to 52% (57/110) of parents reported more confidence regarding leaflet suggestions and up to 47% (49/105) reported positive behaviour changes. Evaluation of brief intervention approaches may help address perceived barriers to undertaking childhood obesity prevention work in primary care in the UK.

To explore the views and experiences of obese patients prescribed anti-obesity drugs in primary care, including their understanding of guidance about lifestyle changes.

Pharmacotherapy treatments are increasingly used to support obesity management. Currently, two anti-obesity drugs are available on the National Health Service (NHS): Orlistat and Sibutramine. Although detailed clinical guidelines for their use are well documented, there is little research about how obese individuals experience and view these drugs in routine care.

Qualitative design with semi-structured interviews conducted in participants’ homes or a health centre. Participants recruited from three general practices in Sheffield with socio-economically diverse populations using purposive sampling. Interviews transcribed verbatim and analysed using the ‘framework’ approach.

Health concerns are the key factor for patients seeking help with weight loss. Participants are typically ambivalent about taking anti-obesity drugs and expectations vary from unreasonably sceptical to unreasonably optimistic. There appears to be high awareness of the need for lifestyle change. Those prescribed Orlistat understood how it worked, however, those on Sibutramine and Rimonabant did not. Participants’ experiences in taking anti-obesity drugs varied greatly and changed with experiences of weight loss, side effects and quality of support. Most could identify points at which the information, choice and support provided by primary care could be improved. However, most were not aware of other avenues of support.

This study has identified a number of areas for service improvement. Better understanding of patient expectations around anti-obesity drugs should help the NHS to shape services to meet needs and make the experiences of patients more positive.

The aim of this study was to describe how healthcare professionals experience and perceive the use of interpreters in their contacts with patients with whom they do not share a common language.

Language barriers lead to poor-quality care and fewer medical contacts. To avoid language barriers and their consequences, interpreters are recommended. However, communicating through an interpreter can be difficult. To develop effective interpreter service it is important to study healthcare staff’s perceptions of using an interpreter.

An explorative descriptive study design was used. The study was conducted in different healthcare settings in Sweden and included 24 healthcare staff, of whom 11 were physicians, 9 nurses, 2 physiotherapists and 2 assistant nurses. Data were generated through written descriptions of the use of interpreters in healthcare service and were analysed using qualitative content analysis.

Two main categories emerged from the data: 1) aspects related to the interpreter and 2) organizational aspects. The study showed that having a face-to-face, professional, trained interpreter, with a good knowledge of both languages and of medical terminology, translating literally and objectively, was perceived positively. The organizational aspects that affected the perception were functioning or non-functioning technical equipment, calm in the interpretation environment, documentation of the patients’ language ability, respect for the appointed time, and the level of availability and service provided by the interpreter agency. It is important to develop a well-functioning interpreter organization that offers trained interpreters with a professional attitude to improve and ensure cost-effective and high-quality encounters and care.

The aim of the study was to evaluate the impact of hygiene routines and characteristics of the daycare centre (DCC) on sickness absence in preschool children.

In Sweden most children attend daycare outside home during daytime. Daycare outside home results in cognitive and social gains for the children, but it also increases the risk of infectious symptoms. About 17%–30% of the respiratory tract infections in preschool children are due to the daycare stay. Factors of importance for sickness absence in DCC have been studied earlier but no study has had a broader focus on routines and daycare characteristics at the same.

In 2003–2004 a national sample of 138 DCCs were visited by a study nurses who assisted in filling in a questionnaire on hygiene routines and daycare characteristics. Thereafter the DCC reported sickness absence on group level during two weeks in the autumn and two weeks in the spring.

Sickness absence was about 10% both in the autumn and in the spring. Only about 10% of the DCC had written rules about hand washing in children but almost all had unwritten rules. More than 50 children at the DCC and no regular contact with the child health centres were found to be of significant importance for sickness absence using a multiple logistic regression model.

The role of the primary care mental health worker (PCMHW) in providing self-help and signposting to people referred for mild-moderate anxiety and depression is currently being complemented by low-intensity workers training under the government’s improving access to psychological therapies (IAPT) programme.

This study aims to explore the experiences of five PCMHWs working in the context of a newly designed primary care mental health team in London.

Thematic analysis of participants’ written reflective papers provides a qualitative exploration of issues and concerns raised by PCMHWs during a fortnightly reflective practice group.

Themes emerging from participants’ written accounts highlight: difficulties in applying academic and skills training to the real-life world of clinical practice; difficulties in managing issues of risk and complexity; role confusion; and the need for a visible and coherent career structure.

The study highlights the psychological impact on PCMHWs of managing complex client referrals. This is discussed in the context of the high volume case turnover anticipated by IAPT training curricula. Implications for the training and education of IAPT low-intensity workers are briefly considered.

Self-efficacy is an important outcome measure of self-management interventions. We aimed to establish UK validity and reliability of the diabetes management self-efficacy scale (DMSES).

The 20 item DMSES was available for Dutch and US populations. Consultation with people with type 2 diabetes and health professionals established UK content and face validity resulting in item reduction to 15. Participants were adults with type 2 diabetes enrolled in a randomised controlled trial (RCT) of the diabetes manual, a self-management education intervention, with an HbA1c over 7% and who understood English. Baseline trial data and follow-up control group data were used.

A total of 175 participants completed all 15 items. Pearson’s correlation coefficient of −0.46 (P < 0.0001) between the DMSES UK and the problem areas in diabetes scale demonstrated criterion validity. Intra-class correlation between data from 67 of these participants was 0.77, demonstrating test-retest reliability. The correlation coefficients between item scores and total scores were >0.30. Cronbach’s alpha was 0.89 over all items.

This evaluation demonstrates that the scale has good internal reliability, internal consistency, construct validity, criterion validity, and test-retest reliability.

The 15 item DMSES UK is suitable for use in research and clinical settings to measure the self-efficacy of people living with type 2 diabetes in managing their diabetes.

There is widespread, unexplained variation in activity and outcome between general practices.

To explore the relationship between practice size and participation in optional activities, including the Quality and Outcomes Framework (QOF).

Cross-sectional analyses of routinely available data on practice characteristics, QOF performance and optional activities including undergraduate teaching, postgraduate training, research, enhanced clinical data collection and service development.

All 1031 general practices were located in mainland Scotland.

The most popular optional activity was undergraduate medical teaching, which involved 41% of all general practices. About a third of practices took part in postgraduate general practitioner training (29%), research (33%), enhanced clinical data collection through the Scottish Programme for Improving Clinical Effectiveness (31%) and the activities of the Scottish Primary Care Collaborative (33%). The most important driver of the number of activities undertaken by a practice is size with single handed, small and medium sized practices all undertaking a significantly lower number of activities than larger practices (P < 0.001). Deprivation had no overall effect, but was associated with lower rates of participation in postgraduate training. The average number of points achieved in the QOF ranged from 961 by the 18% of practices taking part in no optional activities, to 973 by 29% of practices taking part in one activity, 984 by 25% of practices taking part in two activities and 985 in 28% of practices taking part in three or more activities. Single handed practices in urban areas taking part in three or more additional activities had similar QOF point totals to larger practices taking part in three or more activities, and achieved 44 more QOF points than urban single-handed practices taking part in less than two additional activities.

Practice size is strongly related to participation in optional activities. There is a small but significant relationship between the practice size and number of QOF points achieved by practices taking part in less than two additional activities. Participation in optional activities is a possible indicator of cultural and organisational factors within practices, which constrain the volume and quality of services, which they are able to provide.

The primary objective of this study was to determine whether adults with a chronic illness within a primary care setting who received a rehabilitation intervention in this setting showed greater improvement in health status and had fewer hospital admissions and emergency room visits compared with adults who do not receive the intervention.

More than half of Canadians (16 million people) live with chronic illness. Persons with chronic illness in primary care, especially older persons who are most at risk for functional decline, are currently not receiving effective management.

A randomized controlled trial was used. A rehabilitation multi-component intervention was delivered by a physiotherapist (PT) and occupational therapist in a primary care setting and included collaborative goal setting for rehabilitation needs, a six-week chronic disease self-management (SM) workshop, referral to community programs and a web-based education programme.

Three hundred and three patients participated, n = 152 intervention group and n = 151 in the control group. There was a significant difference between the groups for planned hospital days (F = 6.3, P = 0.00) with an adjusted difference 0.60 day per person, and increased satisfaction with rehabilitation services however no difference on health status or emergency room visits. This rehabilitation intervention which had a strong SM component prevented planned hospitalizations that resulted in a conservative estimated cost saving from reduced hospitalizations of $65 000. Future research needs to examine which patient groups with chronic illness show positive responses to rehabilitation and self-management.

The purpose of this study was to compare return visits in 2 weeks experienced by patients using a retail nurse-practitioner clinic to similar patients using standard drop-in clinic located in a medical office.

Retail medicine clinics have become widely available. However, their impact on return visit rates compared to drop-in medical office visits for similar patients is unknown.

Medical records of primary care patients (both adults and children) seen in a large group practice in Minnesota in 2008 were analyzed for this study. Patients treated for five common conditions were selected (pink eye, sore throat, viral illness, bronchitis, and cough, n = 279). Two groups of patients were studied: those using a retail walk-in clinic staffed by nurse practitioners (n = 142) and a comparison group using regular office care for same-day visits (n = 137). The dependent variable was a return office visit within 2 weeks. Multiple logistic regression analysis was used to adjust for case mix differences between groups.

The percent of office visits within 2 weeks for these groups was 20.4 for retail drop-in patients and 27.7 for same-day medical office patients, respectively (P = 0.15). After adjustment for age, gender, visit reason, and number of office visits in the previous 6 months, no significant difference in risk of early return visits in comparison to an office-based drop-in clinic was found (odds ratio 0.83, confidence interval 0.43–1.63). Our retail nurse-practitioner clinic appeared to increase access without increasing early return visits.

To explore the perspectives of both professionals and older people on modifiable health behaviours and risks in later life.

Promotion of health and prevention of disability in later life are major health policy priorities across Europe. A system for health risk appraisal in later life, health risk appraisal in older people (HRA-O) permits a population-wide assessment to be carried out. The HRA-O technology is a single assessment process-based questionnaire, which generates a computer decision support system, to offer tailored advice about modifying health risks and behaviours.

Qualitative study using nominal groups and interviews.

General practices, National Health Service and local government social services, and voluntary organisations in two London boroughs.

Nominal groups were recruited from general practice, older people’s forums, voluntary organisations and social services departments, and individual interviews were carried out with health and social care commissioners, clinicians, professionals and public health practitioners, which discussed the HRA-O questionnaire.

Public and professional evaluation identified necessary refinements of the HRA-O technology, the need for greater insight into the social psychology of ageing on the part of those engaged in health promotion, and the necessary and appropriate involvement of professionals in reinforcing health promotion advice.

This study discusses the findings from the nominal groups and interviews in the light of the technology’s failure to change self-reported behaviour and places them in the context of current approaches to health promotion for older populations.

We aimed to compare recalled information on medication use, self-care activities and pain intensity among primary care low back pain consulters with diary records of the same events.

Concerns are often expressed regarding the validity of recalled information about past experience of health events such as pain or its treatment. Comparing with information collected using daily diaries is one method of validating recalled findings.

Patients completed diaries recording their medication use, self-care activities and pain intensity each day for two weeks. Immediately following this period, patients completed questionnaires asking for recall of their medication use, self-care activities and least, worst, usual and current pain for the previous two weeks. The recalled information obtained from the questionnaires was compared with data from the daily diaries using intraclass correlation coefficients (ICC) and κ, with one-sided 95% confidence intervals.

All 29 participants returned 11 or more diaries. Validity of questionnaire-based recall for medication use and self-care activities was good, with everyone who reported use in the diaries also reporting this on the questionnaires (both κ = 1.0). However, some specific medications (eg, diclofenac) were over-reported in the questionnaires, and some self-care activities (eg, exercises) were under-reported. Combinations of pain intensity ratings were more accurate than single ratings; the mean of the recalled least, usual and current pain intensities was closest to the diary ratings (ICC 0.94, mean difference 0.13). The generalisability of these findings to other settings, recall periods and patient groups remains to be established.

We investigated patients’ impressions of the effectiveness of treatment provided by health centre physicians. Were the patients’ expectations met, and were the consultations considered effective? Which factors affected consultation success?

The study was conducted in 16 municipalities in the Kanta-Häme region Finland in 2004. Primary healthcare services to these municipalities are provided by five health centres. The municipalities’ total population was 166 648 (31 December 2003).

The data were collected during telephone interviews, supplemented by a mail survey. The study population (2600) was drawn from the Finnish Population Information System by random sampling. A total of 1751 inhabitants participated in the study (response rate: 67%). The respondents were considered able to evaluate treatment effectiveness if they had visited a health centre physician because of an illness or an accident during the past 12 months. Seven hundred and twenty-nine respondents met these criteria.

Most respondents (73%) found that their treatment corresponded with their expectations. According to a logistic regression analysis, the factors that best explained whether the patient’s treatment expectations were met included the physician’s respect for the patient, the consultation duration and the reason for the visit. Of the respondents, 70% thought the consultation had been effective. Factors explaining consultation effectiveness included consultation duration, physician’s respect for the patient and whether the consultation was scheduled within three days. In conclusion, the physician–patient consultations seemed to be very good and clearly worth the effort. Notably, we observed that the same factors helped to explain whether the patient’s treatment expectations were met, and whether the patient found the consultation effective.