Hoffmann, Kathryn; Peersman, Wim; George, Aaron; Dorner, Thomas Ernst
The aim of this analysis was to assess the impact of chronic back pain and psychological distress on the utilization of primary and secondary levels of care in the ambulatory health care sector in Austria - a country without a gatekeeping system. Additionally, we aimed to determine if the joint effect of chronic back pain and psychological distress was higher than the impact of the sum of the two single conditions. The database used for this analysis was the Austrian Health Interview Survey, ...
U.S. Department of Health & Human Services — The National Hospital Ambulatory Medical Care Survey (NHAMCS) is designed to collect data on the utilization and provision of ambulatory care services in hospital...
Full Text Available Abstract Background A relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage. Methods From the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome, we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles and hospitalization rates (RR, 95% CI separately for the selected conditions controlling for age, gender and city of residence. Results Overall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31 and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62. With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year
Misener, Terry R.
A six month project was undertaken to collect outpatient encounter data (demographic, workload, and diagnoses) at a community medical treatment facility. To capture data, the 13,000 patients seen each month, the clerical staff and primary care providers all completed portions of a “mark sense” form. Study results, lessons learned, and a conceptual plan for a future outpatient information system are reviewed.
U.S. Department of Health & Human Services — The National Ambulatory Medical Care Survey (NAMCS) is a national survey designed to meet the need for objective, reliable information about the provision and use...
... the caveats discussed in the ‘‘Methods’’ section. The relationship between characteristics of the patient’s ZIP Code and the choice of ambulatory care setting is shown in Table 5. For persons ...
Singh, Hardeep; Weingart, Saul N.
Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may…
Full Text Available Objective: To determine resident comfort and skill in performing ambulatory care skills. Methods: Descriptive survey of common ambulatory care skills administered to internal medicine faculty and residents at one academic medical center. Respondents were asked to rate their ability to perform 12 physical exam skills and 6 procedures, and their comfort in performing 7 types of counseling, and obtaining 6 types of patient history (4 point Likert scale for each. Self-rated ability or comfort was compared by gender, status (year of residency, faculty, and future predicted frequency of use of the skill. Results: Residents reported high ability levels for physical exam skills common to both the ambulatory and hospital setting. Fewer felt able to perform musculoskeletal, neurologic or eye exams easily alone. Procedures generally received low ability ratings. Similarly, residents comfort in performing common outpatient counseling was also low. More residents reported feeling very comfortable in obtaining history from patients. We found little variation by gender, year of training, or predicted frequency of use. Conclusion: Self-reported ability and comfort for many common ambulatory care skills is low. Further evaluation of this finding in other training programs is warranted.
Thorpe, Jane Hyatt; Gray, Elizabeth Alexandra
Big data is heralded as having the potential to revolutionize health care by making large amounts of data available to support care delivery, population health, and patient engagement. Critics argue that big data's transformative potential is inhibited by privacy requirements that restrict health information exchange. However, there are a variety of permissible activities involving use and disclosure of patient information that support care delivery and management. This article presents an ov...
Simborg, Donald W.; Whiting-O'Keefe, Quinn E.
The central purpose of an ambulatory care information system is to communicate information to the practitioner to facilitate clinical decision making. The clinical decision can be considered the dependent output variable in a process having the information system, the patient, clinician characteristics, and the environment as the independent input variables. Evaluation approaches using patient outcomes are problematic because of the indirect relationship between the information system and pat...
Zillich, Alan J; Saseen, Joseph J; Dehart, Renee M; Dumo, Peter; Grabe, Darren W; Gilmartin, Cheryl; Hachey, David M; Hudson, Joanna Q; Pruchnicki, Maria C; Joy, Melanie S
An increasing number of patients are developing chronic kidney disease (CKD). Appropriate care for patients with CKD must occur in the earliest stages, preferably before CKD progresses to more severe stages. Therefore, recognition and treatment of CKD and its associated complications must occur in primary care settings. Patients with CKD often have comorbid conditions such as diabetes mellitus, hypertension, and dyslipidemia, creating specific considerations when treating these diseases. Also, these patients have CKD-related conditions, including anemia and renal osteodystrophy, that are not traditionally evaluated and monitored by the primary care practitioner. Collectively, many opportunities exist for pharmacists who practice in the primary care setting to improve the care of patients with CKD. PMID:15767229
Moye, Janet P; Swan, Beth Ann
Ambulatory care faces challenges in sustaining a nursing workforce in the future as newly licensed nurses are heavily recruited to inpatient settings and retirements will impact ambulatory care sooner than other areas. Building a diverse team by recruiting nurses of different ages (generations) and skills may result in a more successful and robust organization. Knowledge about generational characteristics and preferences will aid nurse leaders and recruiters in attracting high-quality, talented nurses. Nurses of Generations X and Y can increase their likelihood of success in ambulatory care by better understanding intergenerational issues. PMID:20050492
Alexandre Cruz Henriques
Full Text Available OBJETIVO: Os autores apresentam sua experiência com 50 pacientes operados de colecistectomia videolaparoscópica em regime ambulatorial, no Hospital de Ensino da Faculdade de Medicina do ABC. MÉTODO: Quarenta e dois pacientes (84% eram do sexo feminino e oito (16% do masculino, a idade variou de 23 a 60 anos, com média de 41,5 anos. Foram submetidos ao procedimento pacientes com diagnóstico de colecistite crônica calculosa, que obedeciam aos seguintes critérios: inexistência de colecistite aguda, idade máxima de 60 anos, ausência de suspeita de coledocolitíase, avaliação clínica pré-operatória ASA I ou II, aprovação do paciente quanto ao método e período de internação empregados e presença de acompanhante. O posicionamento da equipe e a técnica utilizada foram os preconizados pela escola americana. RESULTADOS: O tempo cirúrgico variou de 50 minutos a 2 horas, com média de 1 hora e 25 minutos. A colangiografia intra-operatória foi realizada em 35 pacientes (70%, demonstrando coledocolitíase em um caso (2%, que necessitou conversão para cirurgia aberta. As complicações mais freqüentes no período pós-operatório imediato foram náuseas e vômitos em três casos (6%, seguidas de dor abdominal intensa em dois casos (4%. Foram tratados com antieméticos e analgésicos e tiveram a alta hospitalar adiada para o dia seguinte à operação. Quarenta e quatro pacientes (88% tiveram condições de alta no mesmo dia. O período de permanência hospitalar foi entre nove e 12 horas. O retorno ambulatorial era programado para o sétimo e trigésimo dias pós-operatório, não havendo necessidade de reinternação em nenhum caso. CONCLUSÕES: A colecistectomia videolaparoscópica ambulatorial é um procedimento seguro.BACKGROUND: The authors present their experience with 50 patients undergoing videolaparoscopic cholecystectomy in an ambulatory care setting at University Hospital, ABC Medical School. METHODS:Forty-two patients (84
Ambulatory care-sensitive conditions (ACSC) are defined as conditions that lead to a hospital admission of which the onset could have been prevented through a more easily accessible ambulatory sector or one that provides better quality care. They are used by health-care systems as a quality indicator for the ambulatory sector. The definition for ACSC varies internationally. Sets of conditions have been defined and evaluated already in various countries, e. g., USA, England, New Zealand and Canada, but not yet for Germany. Therefore this study aims to evaluate the hospital costs of ACSC in Germany using the National Health Service's set of ACSC. In order to calculate these costs a model has been set up for the time period between 2003 and 2010. It is based on G-DRG browsers issued by the German Institute for the Hospital Remuneration System as required by German law. Within these browsers all relevant DRG-ICD combinations have been extracted. The number of cases per combination was then multiplied by their corresponding cost weights and the average effective base rates. The results were then aggregated into their corresponding ICD groups and then into their respective conditions which lead to the costs per condition and the total costs. The total number of cases and total costs were then compared to another second source. These calculations resulted in 11.7 million cases, of which 10.7% were defined as ambulatory care-sensitive. Within the analysed time period the number of ambulatory care-sensitive cases increased by 6% in total and had a 0.9% CAGR. The corresponding costs amounted to a total of EUR 37.6B and to EUR 3.3B for ACSC. 60% of the costs were caused by three of the 19 ACSC. These results validate that it is worthwhile to further investigate this quality indicator for the ambulatory sector. PMID:25918929
Allen, Juliet Walshe
Registered nurses (RNs) struggle when transitioning from the inpatient setting to the outpatient clinical environment because it results in a diverse skill-set shift. The RN, considered an outpatient revenue source, experiences a decrease in peer-to-peer relationships, changes in leadership responsibilities, and changes in workgroup dynamics (supervision of unlicensed clinical personnel who function under the direction of the physician, not the RN). Ambulatory organizations find themselves implementing clinical orientation programs that may not delineate the attributes of the RN. This diminishes their value while emphasizing the unlicensed technical skill set. Creating a core RN orientation program template is paramount for the transition of the RN to the ambulatory setting. The literature reveals several areas where improving the value of the RN will ultimately enhance recruitment and retention, patient care outcomes, and leverage the RN role within any organization. Eleven 30-minute in-depth telephone interviews were conducted in addition to 4 nurse observations to explore the lived experience of the RN in ambulatory care. The findings disclosed an overarching theme of nurse isolation and offered insightful underpinnings for the nurse leader as ambulatory growth continues and nurse leaders further endorse the RN presence in the ambulatory setting. PMID:26938183
Full Text Available Zakaria Messieha Department of Anesthesiology, University of Illinois at Chicago, Chicago, IL, USA Abstract: Ambulatory surgical and anesthesia care (ASAC, also known as Same Day Surgery or Day Care in some countries, is the fastest growing segment of ambulatory surgical and anesthesia care. Over 50 million ambulatory surgical procedures are conducted annually comprising over 60% of all anesthesia care with an impressive track record of safety and efficiency. Advances in ambulatory anesthesia care have been due to newer generation of inhalation and intravenous anesthetics as well as airway management technology and techniques. Successful ambulatory anesthesia care relies on patient selection, adequate facilities, highly trained personnel and quality improvement policies and procedures. Favoring one anesthetic technique over the other should be patient and procedure-specific. Effective management of post-operative pain as well as nausea and vomiting are the final pieces in assuring success in ambulatory anesthesia care. Keywords: ambulatory anesthesia, out-patient anesthesia, Day-Care anesthesia
Powers, Sharon; Bacon, Cynthia Thornton
The implementation of shared governance structures in acute care has illustrated the positive relationship between shared decision making and nurse empowerment and positive nurse and patient outcomes. Little is known, however, about interdisciplinary shared governance, and even less is known about shared governance in ambulatory care. This article details one health system's experience with the implementation of an interdisciplinary shared governance structure in ambulatory care over a 4-year period. The authors report lessons learned, positive health system outcomes that resulted including improved communication, better preparedness for accreditation visits, improved assessment of fall risk, and a streamlined documentation system. Also discussed are mechanisms to enhance sustainability of the structure and discussion of future opportunities and challenges. PMID:27259130
Reynolds, Robert E.
Defines and depicts graphically the relationships between primary, secondary, and tertiary care functions (from least to most intensified phases of medical care); ambulatory care (care of sick or well people not confined to bed); and family medicine (an emerging medical discipline focusing on complete and longterm care of the family). (JT)
Full Text Available Abstract
Background: Hospitalization may often be prevented by timely and effective outpatient care either by preventing the onset of an illness, controlling an acute illness or managing a chronic disease with an appropriate follow-up. The objective of the study is to examine the variability of hospital admissions within Italian regions for Ambulatory Care Sensitive Conditions (ACSCs, and their relationship with primary care supply.
Methods: Hospital discharge data aggregated at a regional level collected in 2005 were analysed by type of ACS conditions. Main outcome measures were regional hospital admission rates for ACSCs. Negative binomial models were used to analyse the association with individual risk factors (age and gender and regional risk factors (propensity to hospitalisation and prevalence of specific conditions.
Non-parametric correlation indexes between standardised hospital admission rates and quantitative measures of primary care services were calculated.
Results: ACSC admissions accounted for 6.6% of total admissions, 35.7% were classified as acute conditions and 64.3% as chronic conditions. Admission rates for ACSCs varied widely across Italian regions with different patterns for chronic and acute conditions. Southern regions showed significantly higher rates for chronic conditions and North-eastern regions for acute conditions. We found a significant negative association between the provision of ambulatory specialist services and standardised hospitalization rates
(SHR for ACS chronic conditions (r=-0.50; p=0.02 and an inverse correlation among SHR for ACS acute conditions and the rate of GPs per 1,000 residents, although the latter was not statistically significant.
Conclusions: In Italy, about 480,000 inpatient hospital admissions in 2005 were attributable to ACSCs. Even
adjusting for potential confounders
Tyler, R D
One of the most utilitarian developments in the field of quality assurance in health care has been the introduction of industrial concepts of quality management. These concepts, coupled with buyer demand for accountability, are bringing new perspectives to health care quality assurance. These perspectives provide a new view of quality assurance as a major responsibility and strategic opportunity for management; a competitive and marketable commodity; and a method of improving safety, effectiveness, and satisfaction with medical care. PMID:10313405
Talwalkar, Jaideep S.; Satcher, D’Juanna; Turner, Teri L.; Sisson, Stephen D.; Fenick, Ada M.
Introduction Extramural curricula developed for the purpose of sharing with other institutions have been designed to improve education on important topics in ambulatory care. We sought to assess the usage rates of these curricula among paediatric, internal medicine, and combined medicine-paediatrics residency programmes in the United States. Methods Surveys on aspects of trainee continuity clinic were sent to paediatric and medicine-paediatrics programme directors in 2012. Surveys contained a...
O'Neill, Sarah; Calderon, Sherry; Casella, Joanne; Wood, Elizabeth; Carvelli-Sheehan, Jayne; Zeidel, Mark L
Effective scheduling of and ready access to doctor appointments affect ambulatory patient care quality, but these are often sacrificed by patients seeking care from physicians at academic medical centers. At one center, Beth Israel Deaconess Medical Center, the authors developed interventions to improve the scheduling of appointments and to reduce the access time between telephone call and first offered appointment. Improvements to scheduling included no redirection to voicemail, prompt telephone pickup, courteous service, complete registration, and effective scheduling. Reduced access time meant being offered an appointment with a physician in the appropriate specialty within three working days of the telephone call. Scheduling and access were assessed using monthly "mystery shopper" calls. Mystery shoppers collected data using standardized forms, rated the quality of service, and transcribed their interactions with schedulers. Monthly results were tabulated and discussed with clinical leaders; leaders and frontline staff then developed solutions to detected problems. Eighteen months after the beginning of the intervention (in June 2007), which is ongoing, schedulers had gone from using 60% of their registration skills to over 90%, customer service scores had risen from 2.6 to 4.9 (on a 5-point scale), and average access time had fallen from 12 days to 6 days. The program costs $50,000 per year and has been associated with a 35% increase in ambulatory volume across three years. The authors conclude that academic medical centers can markedly improve the scheduling process and access to care and that these improvements may result in increased ambulatory care volume. PMID:22193182
Objective To explore the features and influencing factors of ambulatory blood pressure in chronic kidney disease(CKD)patients.Methods A total of 540 CKD patients from May 2010 to May 2012 in our department
... role in making health care safe. That includes doctors, nurses and other health care professionals. Health care organizations ... embarrassed if you don't understand what your doctor, nurse or other health care professional tells you. • Don’ ...
Klarich, Mark J; Rea, Ronald W; Lal, Tarun Mohan; Garcia, Angel L; Steffens, Fay L
Demand for ambulatory care visits is projected to increase 22% between 2008 and 2025. Given this growth, ambulatory care managers need to proactively plan for efficient use of scarce resources (ie, space, equipment, and staff). One important component of ambulatory care space (the number of examination rooms) is dependent on multiple factors, including variation in demand, hours of operation, scheduling, and staff. The authors (1) outline common data collection methods, (2) highlight analysis and reporting considerations for examination room utilization, and (3) provide a strategic framework for short- and long-term decision making for facility design or renovation. PMID:27232683
Crivaldo Gomes Cardoso Jr
Full Text Available Hypertension is a ubiquitous and serious disease. Regular exercise has been recommended as a strategy for the prevention and treatment of hypertension because of its effects in reducing clinical blood pressure; however, ambulatory blood pressure is a better predictor of target-organ damage than clinical blood pressure, and therefore studying the effects of exercise on ambulatory blood pressure is important as well. Moreover, different kinds of exercise might produce distinct effects that might differ between normotensive and hypertensive subjects. The aim of this study was to review the current literature on the acute and chronic effects of aerobic and resistance exercise on ambulatory blood pressure in normotensive and hypertensive subjects. It has been conclusively shown that a single episode of aerobic exercise reduces ambulatory blood pressure in hypertensive patients. Similarly, regular aerobic training also decreases ambulatory blood pressure in hypertensive individuals. In contrast, data on the effects of resistance exercise is both scarce and controversial. Nevertheless, studies suggest that resistance exercise might acutely decrease ambulatory blood pressure after exercise, and that this effect seems to be greater after low-intensity exercise and in patients receiving anti-hypertensive drugs. On the other hand, only two studies investigating resistance training in hypertensive patients have been conducted, and neither has demonstrated any hypotensive effect. Thus, based on current knowledge, aerobic training should be recommended to decrease ambulatory blood pressure in hypertensive individuals, while resistance exercise could be prescribed as a complementary strategy.
Full Text Available Corey Collins Massachusetts Eye and Ear Infirmary, Department of Anesthesiology, Harvard Medical School, Boston, MA, USA Abstract: Pediatric tonsillectomy is a common surgery around the world. Surgical indications are obstructive sleep apnea and recurrent tonsillitis. Despite the frequency of tonsillectomy in children, most aspects of perioperative care are supported by scant evidence. Recent guidelines provide important recommendations although clinician adherence or awareness of published guidance is variable and inconsistent. Current guidelines establish criteria for screening children for post-tonsillectomy observation, though most are based on low-grade evidence or consensus. Current recommendations for admission are: age <3 years; significant obstructive sleep apnea; obesity; and significant comorbid medical conditions. Recent reports have challenged each criterion and recommend admission criteria that are based on clinically relevant risks or observed clinical events such as adverse respiratory events in the immediate recovery period. Morbidity and mortality are low though serious complications occur regularly and may be amenable to improvements in postoperative monitoring, improved analgesic regimens, and parental education. Careful consideration of risks attributable to individual patients is vital to determine overall suitability for ambulatory discharge. Keywords: adverse airway events, complications, guidelines, mortality, OSA, pediatric anesthesia
McLeod, P. J.; Meagher, T W
OBJECTIVE: To determine the status of ambulatory care training of core internal medicine residents in Canada. DESIGN: Mail survey. PARTICIPANTS: All 16 program directors of internal medicine residency training programs in Canada. OUTCOME MEASURES: The nature and amount of ambulatory care training experienced by residents, information about the faculty tutors, and the sources and types of patients seen by the residents. As well, the program directors were asked for their opinions on the ideal ...
Ladden, Maryjoan D; Bodenheimer, Thomas; Fishman, Nancy W; Flinter, Margaret; Hsu, Clarissa; Parchman, Michael; Wagner, Edward H
Many primary care practices are changing the roles played by the members of their health care teams. The purpose of this article is to describe some of these new roles, using the authors' preliminary observations from 25 site visits to high-performing primary care practices across the United States in 2012-2013. These sites visits, to practices using their workforce creatively, were part of the Robert Wood Johnson Foundation-funded initiative, The Primary Care Team: Learning From Effective Ambulatory Practices.Examples of these new roles that the authors observed on their site visits include medical assistants reviewing patient records before visits to identify care gaps, ordering and administering immunizations using protocols, making outreach calls to patients, leading team huddles, and coaching patients to set self-management goals. The registered nurse role has evolved from an emphasis on triage to a focus on uncomplicated acute care, chronic care management, and hospital-to-home transitions. Behavioral health providers (licensed clinical social workers, psychologists, or licensed counselors) were colocated and integrated within practices and were readily available for immediate consults and brief interventions. Physicians have shifted from lone to shared responsibility for patient panels, with other team members empowered to provide significant portions of chronic and preventive care.An innovative team-based primary care workforce is emerging. Spreading and sustaining these changes will require training both health professionals and nonprofessionals in new ways. Without clinical experiences that model this new team-based care and role models who practice it, trainees will not be prepared to practice as a team. PMID:24128622
Frigola Capell, E.; Comin-Colet, J.; Davins-Miralles, J.; Gich-Saladich, I.J.; Wensing, M.; Verdu-Rotellar, J.M.
INTRODUCTION AND OBJECTIVES: Scarce research has been performed in ambulatory patients with chronic heart failure in the Mediterranean area. Our aim was to describe survival trends in our target population and the impact of prognostic factors. METHODS: We carried out a population-based retrospective
Clausen, P; Feldt-Rasmussen, B; Ladefoged, Jens
The circadian pattern of blood pressure variation was investigated in 10 patients with advanced chronic renal failure on continuous ambulatory peritoneal dialysis (CAPD) and in an age-matched group of controls without renal disease with similar office blood pressure level. Monitoring was done using...
Freund, T.; Campbell, S.M.; Geissler, S.; Kunz, C.U.; Mahler, C.; Peters-Klimm, F.; Szecsenyi, J.
PURPOSE: Hospitalizations for ambulatory care-sensitive conditions (ACSCs) are seen as potentially avoidable with optimal primary care. Little is known, however, about how primary care physicians rate these hospitalizations and whether and how they could be avoided. This study explores the complex c
Balogh, Robert S.; Ouellette-Kuntz, Helene; Brownell, Marni; Colantonio, Angela
Background: There is evidence that the primary care provided for persons with an intellectual disability living in the community has been inadequate. Hospitalization rates for ambulatory care sensitive (ACS) conditions are considered an indicator for access to, and quality of, primary care. The objective of this research was to identify ACS…
Barnes, Kelli D; Maguire, Michelle; Bennett, Marialice S
Objective. To determine the impact of an elective course on students' perception of opportunities and of their preparedness for patient care in community and ambulatory pharmacy settings. Design. Each course meeting included a lecture and discussion to introduce concepts and active-learning activities to apply concepts to patient care or practice development in a community or ambulatory pharmacy setting. Assessment. A survey was administered to students before and after the course. Descriptive statistics were used to assess student responses to survey questions, and Wilcoxon signed rank tests were used to analyze the improvement in student responses with an alpha level set at 0.05. Students felt more prepared to provide patient care, develop or improve a clinical service, and effectively communicate recommendations to other health care providers after course completion. Conclusion. This elective course equipped students with the skills necessary to increase their confidence in providing patient care services in community and ambulatory settings. PMID:27168617
Background Ambulatory training in internal medicine has been noted to be dysfunctional and inadequate. In this study, we developed a set of competency-based outcomes specific to ambulatory care to guide the design, implementation and evaluation of instructional events to ensure that societal needs are addressed. Methods In 2007 a Delphi technique was used to reach consensus and define the priorities for competency-based training in ambulatory care for internal medicine residents. Four groups ...
Magarian, Edward O.; And Others
An interdisciplinary project provided ambulatory care clinical training for pharmacy and nursing students in community-based pharmacies, promoting early detection and medical follow-up of common health problems within the community. Students learned new clinical skills in patient health assessment, new diagnostic technologies, patient education…
Polo, Isabel; And Others
A clinical geriatric pharmacy clerkship containing three separate practice areas (long-term, acute, and ambulatory care) is described. The program follows the medical education clerkship protocol, with a clinical pharmacy specialist, pharmacy practice resident, and student. Participation in medical rounds, interdisciplinary conferences, and…
Thorpe, Jane Hyatt; Gray, Elizabeth Alexandra
Big data is heralded as having the potential to revolutionize health care by making large amounts of data available to support care delivery, population health, and patient engagement. Critics argue that big data's transformative potential is inhibited by privacy requirements that restrict health information exchange. However, there are a variety of permissible activities involving use and disclosure of patient information that support care delivery and management. This article presents an overview of the legal framework governing health information, dispels misconceptions about privacy regulations, and highlights how ambulatory care providers in particular can maximize the utility of big data to improve care. PMID:25401945
OBJECTIVE: Atrial fibrillation (AF) substantially increases risk of stroke. Evidence suggests that anticoagulation to reduce risk is underused (a "care gap"). Our objectives were to clarify measures of this gap in care by including data from family physicians and to determine why eligible patients were not receiving anticoagulation therapy. DESIGN: Telephone survey of family physicians regarding specific patients in their practices. SETTING: Nova Scotia. PARTICIPANTS: Ambulatory AF patients n...
The ambulatory health care center has an empirical need to maintain adequate policies and procedures designed to safeguard the health and physical safety of both clients and employees. Of particular concern is the health care worker's risk of injury or exposure to infection. This article discusses the development of a comprehensive employee-safety and infection-control manual. Such a manual can assist in the accreditation of an ambulatory health care center by a national accrediting organization, and can also serve as a risk-management tool. An example of a manual's table of contents, a specific policy/procedure, a waiver form regarding human immunodeficiency virus exposure, and a hepatitis B virus "vaccination status" form are provided. Additionally, two "quick-look" texts are presented as examples of fast reference guides for common safety practices and the treatment of the employee with a health-threatening exposure. PMID:1905791
Acton, K J; Preston, S; Rith-Najarian, S
THE AUTHORS EXAMINED THE PREVALENCE of clinically diagnosed hypertension among all American Indian and Alaska Native outpatients served in Indian Health Service (IHS) facilities in fiscal year 1992, and compared these rates with a similar analysis done in 1987. In this report they provided data on that analysis as well as on the association between hypertension and diabetes. The 1992 overall estimated age-adjusted prevalence of clinically diagnosed hypertension in adults older than age 15 was 10.4%, compared with 10.9% in 1987, a small but significant decrease. Considerable variation exists in hypertension prevalence rates in American Indian communities as analyzed by IHS service area. This report represents an attempt to use ambulatory patient care data to demonstrate a means for ongoing surveillance of a chronic disease for the entire service population of the IHS. This comprehensive data set represents approximately 60% of the entire U.S. American Indian and Alaska Native population. Based on the ongoing nature of this ambulatory patient care data system, this model for hypertension surveillance permits a unique opportunity for longitudinal evaluation of quality improvement efforts for the American Indian and Alaska Native populations served by the IHS. PMID:8898769
BACKGROUND: Ambulatory care sensitive conditions (ACSCs) are conditions for which the provision of timely and effective outpatient care can reduce the risks of hospitalisation by preventing, controlling or managing a chronic disease or condition. AIMS: The aims of this study were to report on ACSCs in Ireland, and to provide a baseline for future reference. METHODS: Using HIPE, via Health Atlas Ireland, inpatient discharges classified as ACSCs using definitions from the Victorian ACSC study were extracted for the years 2005-2008. Direct methods of standardisation allowed comparison of rates using the EU standard population as a comparison for national data, and national population as comparison for county data. Costs were estimated using diagnosis-related groups. RESULTS: The directly age-standardised discharge rate for ACSC-related discharges increased slightly, but non-significantly, from 15.40 per 1,000 population in 2005 to 15.75 per 1,000 population in 2008. The number of discharges increased (9.5%) from 63,619 in 2005 to 69,664 in 2008, with the estimated associated hospital costs increasing (31.5%) from
Full Text Available Objective: To introduce pharmacists to the process, challenges, and opportunities of creating transitions of care (TOC models in the inpatient, ambulatory, and community practice settings. Methods: TOC literature and resources were obtained through searching PubMed, Ovid, and GoogleScholar. The pharmacist clinicians, who are the authors in this manuscript are reporting their experiences in the development, implementation of, and practice within the TOC models. Results: Pharmacists are an essential part of the multidisciplinary team and play a key role in providing care to patients as they move between health care settings or from a health care setting to home. Pharmacists can participate in many aspects of the inpatient, ambulatory care, and community pharmacy practice settings to implement and ensure optimal TOC processes. This article describes establishing the pharmacist’s TOC role and practicing within multiple health care settings. In these models, pharmacists focus on medication reconciliation, discharge counseling, and optimization of medications. Additionally, a checklist has been created to assist other pharmacists in developing the pharmacist’s TOC roles in a practice environment or incorporating more TOC elements in their practice setting. Conclusion: Optimizing the TOC process, reducing medication errors, and preventing adverse events are important focus areas in the current health care system, as emphasized by The Joint Commission and other health care organizations. Pharmacists have the unique opportunity and skillset to develop and participate in TOC processes that will enhance medication safety and improve patient care.
Sen S.; Bowen JF; Ganetsky VS; Hadley D; Melody K; Otsuka S; Vanmali R; Thomas T
Objective: To introduce pharmacists to the process, challenges, and opportunities of creating transitions of care (TOC) models in the inpatient, ambulatory, and community practice settings. Methods: TOC literature and resources were obtained through searching PubMed, Ovid, and GoogleScholar. The pharmacist clinicians, who are the authors in this manuscript are reporting their experiences in the development, implementation of, and practice within the TOC models. Results: Pharmacists are...
Prior, Anders; Vestergaard, Mogens; Davydow, Dimitry S;
BACKGROUND: Psychiatric disorders are associated with an increased risk for ambulatory care-sensitive condition (ACSC)-related hospitalizations, but it remains unknown whether this holds for individuals with nonsyndromic stress that is more prevalent in the general population. OBJECTIVES.......67) after fully adjusting for multimorbidity and socioeconomic factors. Individuals with above reference stress levels experienced 1703 excess ACSC-related hospitalizations (18% of all). A dose-response relationship was observed between perceived stress and the ACSC-related hospitalization rate regardless...
Böcken Jan; Dieterle Wilfried E; Schnee Melanie; Kempkens Daniela; Butzlaff Martin; Rieger Monika A
Abstract Background There has been little systematic research about the extent to which German physicians accept or reject the concept and practice of a) clinical practice guidelines (CPG) and b) evidence based medicine (EBM) The aim of this study was to investigate German office-based physicians' perspective on CPGs and EBM and their application in medical practice. Methods Structured national telephone survey of ambulatory care physicians, four thematic blocks with 21 questions (5 point Lik...
Beaver, Clara; Magnan, Morris A; Henderson, Denise; DeRose, Patricia; Carolin, Kathleen; Bepler, Gerold
A nursing quality consortium standardized nursing practice across 17 independently functioning ambulatory oncology sites. Programs were developed to validate both competences and competencies. One program assessed nine competences needed to develop systems of care to detect and treat treatment-related side effects. A second program was developed to assess competencies needed to prevent harm to oncology patients. This manuscript describes a successful approach to standardizing nursing practice across geographically distant academic and community sites. PMID:26985750
Beans, Bruce E
An American Society of Health-System Pharmacists Research and Education Foundation report predicts trends in health care delivery and financing, drug development and therapeutics, pharmaceutical marketplace, pharmacy workforce, and more. PMID:27069342
Maria Aparecida Araújo Figueiredo
Full Text Available Objective:analyzethe extent to which the incidence rate of primary care sensitivehospitalizations in children under five years is influenced by the percentage of coverage of theprimary care.Methods:This was a cross-sectional ecological study that combines coverage ofprimary careand theambulatorycare-sensitiveconditionsin 2000 and 2010. We used data from theHospital Information System (HIS and the Information System of Primary Care (SIAB.Results:The data revealed that the increased coverage providedprimary carereductionrateofhospitalization diseases studied. In 2000 the reduction was greater for gastroenteritis (51% inchildren under 01 years and 30% in children 01-04 years in 2010 for respiratory diseases (51% inchildren under 01years and 33% in children aged 01-04 years.Conclusion:we found an association between the coverage ofprimary careand admission rates, however seem to affect othervariables, suggesting the need for further studies.
Corey Collins Massachusetts Eye and Ear Infirmary, Department of Anesthesiology, Harvard Medical School, Boston, MA, USA Abstract: Pediatric tonsillectomy is a common surgery around the world. Surgical indications are obstructive sleep apnea and recurrent tonsillitis. Despite the frequency of tonsillectomy in children, most aspects of perioperative care are supported by scant evidence. Recent guidelines provide important recommendations although clinician adherence or awareness of published ...
Thomsen, Linda Aagaard; Winterstein, Almut G; Søndergaard, Birthe;
(1993-March 2007), EMBASE (1980-February 2007), and Web of Science (1945-March 2007). Key words included medication error, adverse drug reaction, iatrogenic disease, outpatient, ambulatory care, primary health care, general practice, patient admission, hospitalization, observational study, retrospective.......5 per 1000 person-months. Cardiovascular drugs, analgesics, and hypoglycemic agents together accounted for 86.5% of pADEs, and 77.2% of pADEs resulted in symptoms of the central nervous system, electrolyte/renal system, and gastrointestinal tract. Medication errors resulting in pADEs occurred in the...
Zhang, Wanqing; Mueller, Keith J.; Chen, Li-Wu; Conway, Kevin
Context: Hospitalization due to ambulatory care sensitive conditions (ACSCs) is often used as an indicator for measuring access to primary care. Rural health clinics (RHCs) provide basic primary care services for rural residents in health professional shortage areas (HPSAs). The relationship between RHCs and ACSCs is unclear. Purpose: The purpose…
Balogh, R.; Brownell, M.; Ouellette-Kuntz, H.; Colantonio, A.
Background: There is evidence that persons with an intellectual disability (ID) face barriers to primary care; however, this has not been extensively studied at the population level. Rates of hospitalisation for ambulatory care sensitive conditions are used as an indicator of access to, and quality of, primary care. The objective of the study was…
Tania Cristina Morais Santa Barbara Rehem
Full Text Available OBJECTIVE: to estimate the sensitivity, specificity and positive and negative predictive values of the Unified Health System's Hospital Information System for the appropriate recording of hospitalizations for ambulatory care-sensitive conditions. METHOD: the hospital information system records for conditions which are sensitive to ambulatory care, and for those which are not, were considered for analysis, taking the medical records as the gold standard. Through simple random sampling, a sample of 816 medical records was defined and selected by means of a list of random numbers using the Statistical Package for Social Sciences. RESULT: the sensitivity was 81.89%, specificity was 95.19%, the positive predictive value was 77.61% and the negative predictive value was 96.27%. In the study setting, the Hospital Information System (SIH was more specific than sensitive, with nearly 20% of care sensitive conditions not detected. CONCLUSION: there are no validation studies in Brazil of the Hospital Information System records for the hospitalizations which are sensitive to primary health care. These results are relevant when one considers that this system is one of the bases for assessment of the effectiveness of primary health care.
Bone metabolism inpatients with chronic renal failure treated by continuous ambulatory peritoneal dialysis (CAPD) was evaluated. IRMA, RRA and RIA were used to detect PTH, 25 (OH)D3, 1,25(OH)2D3, BGP, Ca and P levels in the blood of 24 CAPD patients. PTH and BGP were increased in uremic patients ad decreased after CAPD. 25(OH)D3 and 1,25 (OH)2D3 were decreased in the patients, but their levels were not changed further after CAPD. PTH had negative correlation with 25 (OH)D3 (r = -0.379, P 2D3 (r = -0.451, P < 0.01). PTH had positive correlation with BGP (r 0.501, P < 0.01) in CAPD patients, and the correlativity was decreased by CAPD. The results showed: PTH hypersecretion is a main factor inducing bone metabolism disturbance, and bone turnover rate is decreased in these patients by CAPD
Sclerosing encapsulating peritonitis is a well recognized, but uncommon, complication of chronic ambulatory peritoneal dialysis. I report a case of sclerosing encapsulating peritonitis in which percutaneous catheter drainage was performed preoperatively. Ultrasonography(US) and computed tomography(CT) showed a large multi-septated cystic mass which occupied nearly all the peritoneal cavity. Percutaneous drainage with two 8.5 French catheters was preoperatively performed under fluoroscopy and about 2100 ml of bloody fluid was drained for 20 days. On follow-up CT, the size of the cyst had significantly decreased and anoperation was performed. It is considered that percutaneous catheter drainage is useful in the preoperative decompression of sclerosing encapsulating peritonitis
von Plessen, Christian; Aslaksen, Aslak
PROBLEM: Most patients with advanced lung cancer currently receive much of their health care, including chemotherapy, as outpatients. Patients have to deal with the complex and time consuming logistics of ambulatory cancer care. At the same time, members of staff often waste considerable time and...... energy in organisational aspects of care that could be better used in direct interaction with patients. DESIGN: Quality improvement study using direct observation and run and flow charts, and focus group meetings with patients and families regarding perceptions of the clinic and with staff regarding...... satisfaction with working conditions. SETTING: Thoracic oncology outpatient clinic at a Norwegian university hospital where patients receive chemotherapy and complementary palliative care. KEY MEASURES FOR IMPROVEMENT: Waiting time and time wasted during consultations; calmer working situation at the clinic...
Carrol, N V; Gagon, J P
Because of increasing competition, it is becoming more important that health care providers pursue consumer-based market segmentation strategies. This paper presents a methodology for identifying and describing consumer segments in health service markets, and demonstrates the use of the methodology by presenting a study of consumer segments in the ambulatory care pharmacy market. PMID:10262855
Franks, Andrea S.; Guirguis, Alexander B.; George, Christa M.; Howard-Thompson, Amanda; Heidel, Robert E.
Objectives To assess students' performance and perceptions of team-based and mixed active-learning methods in 2 ambulatory care elective courses, and to describe faculty members' perceptions of team-based learning. Methods Using the 2 teaching methods, students' grades were compared. Students' perceptions were assessed through 2 anonymous course evaluation instruments. Faculty members who taught courses using the team-based learning method were surveyed regarding their impressions of team-based learning. Results The ambulatory care course was offered to 64 students using team-based learning (n = 37) and mixed active learning (n = 27) formats. The mean quality points earned were 3.7 (team-based learning) and 3.3 (mixed active learning), p < 0.001. Course evaluations for both courses were favorable. All faculty members who used the team-based learning method reported that they would consider using team-based learning in another course. Conclusions Students were satisfied with both teaching methods; however, student grades were significantly higher in the team-based learning course. Faculty members recognized team-based learning as an effective teaching strategy for small-group active learning. PMID:21301594
Lenders, Carine M; Manders, Aaron J; Perdomo, Joanna E; Ireland, Kathy A; Barlow, Sarah E
Since the "2007 summary report of child and adolescent overweight and obesity treatment" published by Barlow, many obesity intervention studies have been conducted in pediatric ambulatory care. Although several meta-analyses have been published in the interim, many studies were excluded because of the focus and criteria of these meta-analyses. Therefore, the primary goal of this article was to identify randomized case-control trials conducted in the primary care setting and to report on treatment approaches, challenges, and successes. We have developed four themes for our discussion and provide a brief summary of our findings. Finally, we identified major gaps and potential solutions and describe several urgent key action items. PMID:27048522
Phillips, J H
Each stage of a product's life cycle requires marketing strategy modifications in response to changing demand levels. The purpose of this study was to investigate changes in ambulatory care center (ACC) operational characteristics indicative of product, market, and distribution channel adjustments that could have a competitive impact upon community pharmacy practice. A questionnaire was mailed to a national sample of 325 ACC managers. Evidence of new product feature additions includes increased emphasis on continued care and increased prevalence of prescription drug dispensing. Expansion into new market segments and distribution channels was demonstrated by increased participation in HMO and employer relationships. The observed adjustments in ACC marketing strategies present obvious challenges as well as less obvious opportunities for community pharmacy practice. PMID:10295634
Schmittdiel, Julie A.; Shortell, Stephen M.; Rundall, Thomas G; Bodenheimer, Thomas; SELBY, Joe V.
PURPOSE It has been suggested that the best way to improve chronic illness care is through a redesign of primary care emphasizing comprehensive, coordinated care as espoused by the Chronic Care Model (CCM). This study examined the relationship between primary care orientation and the implementation of the CCM in physician organizations.
Ann M. Fugit, Pharm.D., BCPS; Sallie D. Mayer, Pharm.D., MBA, BCPS, CDE; Radha S. Vanmali, Pharm.D., BCACP
Objective: Describe the role and integration of ambulatory care pharmacists in a Human Immunodeficiency Virus (HIV) clinic within a free and bilingual clinic with regards to types of interventions made during the patient-pharmacist visit. Design: Retrospective, single-centered, chart review. Setting: Free, bilingual clinic in Richmond, VA. Participants: Thirty-two adult patients with diagnosed HIV receiving care in the clinic between June 30, 2010 and January 26, 2011. Main Outcome Measure: T...
Duc, Ha Anh; Sabin, Lora L; Cuong, Le Quang; Thien, Duong Duc; Feeley III, Rich
Background: Over the past two decades, health insurance in Vietnam has expanded nationwide. Concurrently, Vietnam’s private health sector has developed rapidly and become an increasingly integral part of the health system. To date, however, little is understood regarding the potential for expanding public-private partnerships to improve health care access and outcomes in Vietnam. Objective: To explore possibilities for public-private collaboration in the provision of ambulatory care at the pr...
Serrao, Richard A; Orlander, Jay D
In this article, the authors reexamine the Ambulatory Diagnostic and Treatment Center (ADTC) model, which uniquely combines the education of trainees with the care of referred patients at one Veterans Affairs medical center. As an ambulatory clinic with an inpatient mind-set, the ADTC uses a series of closely spaced outpatient appointments that are longer than typical ambulatory visits, offering a VIP-level of evaluation with the patient-centered goal of expedited diagnosis and treatment. Faculty triage patients by weighing factors such as urgency, educational value, complexity, and instability of diseases in conjunction with the resources, availability, and appropriateness of other services within the medical center.The ADTC's unique focus on the education of trainees in comparison with other clinical rotations is evident in the ratio of learning to patient care. This intensive training environment expects postgraduate year 2 and 3 internal medicine residents and fourth-year medical students to read, reflect, and review literature daily. This mix of education and care delivery is ripe for reexploration in light of recent calls for curriculum reform amidst headlines exposing delays in veterans' access to care.A low-volume, high-intensity clinic like the ADTC can augment the clinical services provided by a busy primary care and subspecialty workforce without losing its emphasis on education. Other academic health centers can learn from this model and adapt its structure in settings where accountable care organizations and education meet. PMID:26839944
Characteristics of ambulatory care clinics and pharmacists in Veterans Affairs medical centers. IMPROVE investigators. Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers.
Alsuwaidan, S; Malone, D C; Billups, S J; Carter, B L
The type and extent of ambulatory care clinical pharmaceutical services in selected Veterans Affairs medical centers (VAMCs) were studied as part of a larger project. Questionnaires were sent to the 174 VAMCs to determine the extent of clinical pharmacy activity in ambulatory care clinics, characteristics of outpatient pharmacies and clinics, and characteristics of ambulatory care pharmacists in VAMCs and to identify sites for the IMPROVE (Impact of Managed Pharmaceutical Care on Resource Utilization and Outcomes in Veterans Affairs Medical Centers) project. Fifty VAMCs responded to the survey. There were 512 ambulatory care clinics within these VAMCs. There was some pharmacist coverage in 75% of the clinics. The highest pharmacist coverage was in walk-in refill, therapeutic drug monitoring, and anticoagulation clinics. Clinical pharmacists at 68% of the VAMCs had prescribing privileges in ambulatory care clinics. Clinical pharmacists managed 29.9% of the clinics. The types of clinics most commonly managed by pharmacists were therapeutic drug monitoring, anticoagulation, walk-in refill, and lipid clinics. Nurse practitioners or physician assistants also were providing primary care in 41% of the clinics. There were 242 ambulatory care clinical pharmacy specialists practicing in the 50 VAMCs. Of these, 41.3% had three years or less of ambulatory care experience. Most pharmacists were in the clinic five days per week. A Pharm.D. degree was the highest degree obtained for 76.9%. Ambulatory care pharmaceutical services are common in VAMCs and are being provided by numerous clinical pharmacists. PMID:9437478
Torgovicky, Refael; Goldberg, Avishay; Shvarts, Shifra; Bar Dayan, Yosefa; Onn, Erez; Levi, Yehezkel; BarDayan, Yaron
A number of typologies have been developed in the strategic management literature to categorize strategies that an organization can pursue at the business level. Extensive research has established Porter's generic strategies of (1) cost leadership, (2) differentiation, (3) differentiation focus, (4) cost focus, and (5) stuck-in-the-middle as the dominant paradigm in the literature. The purpose of the current study was to research competitive strategies in the Israeli ambulatory health care system, by comparing managerial perceptions of present and ideal business strategies in two Israeli sick funds. We developed a unique research tool, which reliably examines the gap between the present and ideal status managerial views. We found a relation between the business strategy and performance measures, thus strengthening Porter's original theory about the nonviability of the stuck-in-the-middle strategy, and suggesting the applicability Porter's generic strategies to not-for-profit institutes in an ambulatory health care system. PMID:15773250
Chang, Chirn-Bin; Yang, Shu-yu; Lai, Hsiu-Yun; Wu, Ru-Shu; Liu, Hsing-Cheng; Hsu, Hsiu-Ying; Hwang, Shinn-Jang; Chan, Ding-Cheng (Derrick)
Objective To investigate the national prevalence of potentially inappropriate medications (PIMs) prescribed in ambulatory care clinics in Taiwan according to three different sets of regional criteria and the correlates of PIM use. Design Cross-sectional study. Setting This analysis included older patients who visited ambulatory care clinics in 2009 and represented half of the older population included on the Taiwanese National Health Insurance Research Database. Participants We identified 1 1...
Gong, Young-Hoon; Yoon, Seok-Jun; Seo, Hyeyoung; Kim, Dongwoo
Objectives: The goal of this study was to identify association between the continuity of ambulatory care of diabetes patients in South Korea (hereafter Korea) and the incidence of macrovascular complications of diabetes, using claims data compiled by the National Health Insurance Services of Korea. Methods: This study was conducted retrospectively. The subjects of the study were 43 002 patients diagnosed with diabetes in 2007, who were over 30 years of age, and had insurance claim data from 2...
Full Text Available Abstract Background Medication errors, adverse drug events and potential adverse drug events are common and serious in terms of the harms and costs that they impose on the health system and those who use it. Errors resulting in preventable adverse drug events have been shown to occur most often at the stages of ordering and administration. This paper describes the protocol for a pragmatic trial of electronic prescribing to reduce prescription error. The trial was designed to overcome the limitations associated with traditional study design. Design This study was designed as a 65-week, cluster randomized, parallel study. Methods The trial was conducted within ambulatory outpatient clinics in an academic tertiary care centre in Ontario, Canada. The electronic prescribing software for the study is a Canadian electronic prescribing software package which provides physician prescription entry with decision support at the point of care. Using a handheld computer (PDA the physician selects medications using an error minimising menu-based pick list from a comprehensive drug database, create specific prescription instructions and then transmit the prescription directly and electronically to a participating pharmacy via facsimile or to the physician's printer using local area wireless technology. The unit of allocation and randomization is by 'week', i.e. the system is "on" or "off" according to the randomization scheme and the unit of analysis is the prescription, with adjustment for clustering of patients within practitioners. Discussion This paper describes the protocol for a pragmatic cluster randomized trial of point-of-care electronic prescribing, which was specifically designed to overcome the limitations associated with traditional study design. Trial Registration This trial has been registered with clinicaltrials.gov (ID: NCT00252395
RosiÅczuk,Joanna; Manulik,StanisÅaw; Karniej,Piotr
StanisÅaw Manulik,1 Joanna RosiÅczuk,2 Piotr Karniej3 1Non-Public Health Care Institution, “Ambulatory of Cosmonauts” Ltd. Liability Company, 2Department of Nervous System Diseases, Faculty of Health Science, 3Department of Organization and Management, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland Introduction: Service quality and customer satisfaction are very important components of competitive advantage in the health care sector. The SERVQUA...
Full Text Available Abstract Background There has been little systematic research about the extent to which German physicians accept or reject the concept and practice of a clinical practice guidelines (CPG and b evidence based medicine (EBM The aim of this study was to investigate German office-based physicians' perspective on CPGs and EBM and their application in medical practice. Methods Structured national telephone survey of ambulatory care physicians, four thematic blocks with 21 questions (5 point Likert scale. 511 office-based general practitioners and specialists. Main outcome measures were the application of Clinical Practice Guidelines in daily practice, preference for sources of guidelines and degree of knowledge and acceptance of EBM. In the data analysis Pearson's correlation coefficient was used for explorative analysis of correlations. The comparison of groups was performed by Student's t-test. Chi2 test was used to investigate distribution of two or more categorical variables. Results Of the total study population 55.3% of physicians reported already using guidelines in the treatment of patients. Physicians in group practices (GrP as well as general practitioners (GP agreed significantly more with the usefulness of guidelines as a basis for patient care than doctors in single practices (SP or specialists (S (Student's t-test mean GP 2.57, S 2.84, p Conclusion Despite a majority of physicians accepting and applying CPGs a large group remains that is critical and opposed to the utilization of CPGs in daily practice and to the concept of EBM in general. Doctors in single practice and specialists appear to be more critical than physicians in group practices and GPs. Future research is needed to evaluate the willingness to acquire necessary knowledge and skills for the promotion and routine application of CPGs.
Full Text Available Until recently, Prothrombin Time/International Normalized Ratio (PT/INR measurements have typically been used to monitor patients on warfarin through institutional laboratories via venous puncture. The Point-of-Care Testing (POCT device has revolutionized the patient care process by allowing for laboratory testing outside of the central laboratory. Objective: To analyze humanistic and clinical outcomes in patients currently treated with warfarin and monitored through a pharmacist-managed anticoagulation clinic using point-of-care testing (POCT device versus venipuncture within ambulatory care clinics at our institution. Methods: All patients currently treated with warfarin therapy who were managed by clinical pharmacists for anticoagulation monitoring at the Medical University of South Carolina (MUSC Family Medicine Center and University Diagnostic Center, were enrolled. Patients were asked to complete a satisfaction survey regarding their anticoagulation monitoring. In addition, data related to emergency department (ED visits, hospitalizations and percent of time in the INR therapeutic range for 6 months pre- and post-implementation of POCT device was collected. This information was obtained through an electronic patient information database, Oacis. Results: A total of 145 patients were included in the data collection from the two clinics. The majority (41% of these patients were taking warfarin for atrial fibrillation. Satisfaction surveys were completed by 86 (59 % of patients. The surveys revealed that POCT device was preferred over venipuncture in 95% of patients. Reasons for the preference included more face-to-face interaction, less wait time, less pain, less blood needed, and quicker results. Of the 145 patients who were included in the objective data analysis, no significant differences were found in the number of hospitalizations, ED visits, or percent of time in the INR therapeutic range pre- and post- implementation of POCT device
Ha Anh Duc
Full Text Available Background: Over the past two decades, health insurance in Vietnam has expanded nationwide. Concurrently, Vietnam's private health sector has developed rapidly and become an increasingly integral part of the health system. To date, however, little is understood regarding the potential for expanding public-private partnerships to improve health care access and outcomes in Vietnam. Objective: To explore possibilities for public-private collaboration in the provision of ambulatory care at the primary level in the Mekong region, Vietnam. Design: We employed a mixed methods research approach. Qualitative methods included focus group discussions with health officials and in-depth interviews with managers of private health facilities. Quantitative methods encompassed facility assessments, and exit surveys of clients at the same private facilities. Results: Discussions with health officials indicated generally favorable attitudes towards partnerships with private providers. Concerns were also voiced, regarding the over- and irrational use of antibiotics, and in terms of limited capacity for regulation, monitoring, and quality assurance. Private facility managers expressed a willingness to collaborate in the provision of ambulatory care, and private providers facilites were relatively well staffed and equipped. The client surveys indicated that 80% of clients first sought treatment at a private facility, even though most lived closer to a public provider. This choice was motivated mainly by perceptions of quality of care. Clients who reported seeking care at both a public and private facility were more satisfied with the latter. Conclusions: Public-private collaboration in the provision of ambulatory care at the primary level in Vietnam has substantial potential for improving access to quality services. We recommend that such collaboration be explored by Vietnamese policy-makers. If implemented, we strongly urge attention to effectively managing such
McEvoy, R Doug; Chai-Coetzer, Ching Li; Antic, Nick A
Obstructive sleep apnea has increased in prevalence in recent years and despite the expansion in sleep medicine services there is a significant unmet burden of disease. This burden presents a challenge to specialists and requires a reappraisal of service delivery, including a move toward lower-cost, simplified methods of diagnosis and treatment, an expansion of the sleep apnea workforce to include suitably trained and equipped primary care physicians and nurses, and the incorporation of chronic disease management principles that link patients to relevant community resources and empower them through new technologies to engage more fully in their own care. PMID:27542873
Jeanny Engels; Marjolein Rebel; Doortje Boshuizen
Purpose Implementation and evaluation of a personalized care plan for approximately 350 people with (an increased risk of) cardiovascular disease in ten general practices in the Netherlands. Context The ‘Healthy Vessels’ (‘Vitale Vaten’) care standard of 2009 describes the optimum care for people with (an increased risk of) cardiovascular disease and is based on the Chronic Care Model. New: working with a personalized care plan, with detailed attention for the promotion of self-management and...
U.S. Department of Health & Human Services — The Ambulatory Surgical Center Quality Reporting (ASCQR) Program seeks to make care safer and more efficient through quality reporting. ASCs eligible for this...
Full Text Available OBJECTIVE: To evaluate the characteristics of the patients receiving medical care in the Ambulatory of Hypertension of the Emergency Department, Division of Cardiology, and in the Emergency Unit of the Clinical Hospital of the Ribeirão Preto Medical School. METHODS: Using a protocol, we compared the care of the same hypertensive patients in on different occasions in the 2 different places. The characteristics of 62 patients, 29 men with a mean age of 57 years, were analyzed between January 1996 and December 1997. RESULTS: The care of these patients resulted in different medical treatment regardless of their clinical features and blood pressure levels. Thus, in the Emergency Unit, 97% presented with symptoms, and 64.5% received medication to rapidly reduce blood pressure. In 50% of the cases, nifedipine SL was the elected medication. Patients who applied to the Ambulatory of Hypertension presenting with similar features, or, in some cases, presenting with similar clinically higher levels of blood pressure, were not prescribed medication for a rapid reduction of blood pressure at any of the appointments. CONCLUSION: The therapeutic approach to patients with high blood pressure levels, symptomatic or asymptomatic, was dependent on the place of treatment. In the Emergency Unit, the conduct was, in the majority of cases, to decrease blood pressure immediately, whereas in the Ambulatory of Hypertension, the same levels of blood pressure, in the same individuals, resulted in therapeutic adjustment with nonpharmacological management. These results show the need to reconsider the concept of hypertensive crises and their therapeutical implications.
... Stretch Marks Sun-damaged Skin Unwanted Hair Unwanted Tattoos Varicose Veins Vitiligo Wrinkles Treatments and Procedures Ambulatory ... Stretch Marks Sun-damaged Skin Unwanted Hair Unwanted Tattoos Varicose Veins Vitiligo Wrinkles Treatments and Procedures Ambulatory ...
Balogh, R. S.; Ouellette-Kuntz, H.; Brownell, M.; Colantonio, A.
Background: Hospitalisations for ambulatory care-sensitive (ACS) conditions are used as an indicator of access to, and the quality of, primary care. The objective was to identify factors associated with hospitalisations for ACS conditions among adults with an intellectual disability (ID) in the context of a publicly insured healthcare system.…
Full Text Available Abstract Background Swiss ambulatory care is characterized by independent, and primarily practice-based, physicians, receiving fee for service reimbursement. This study analyses supply sensitive services using ambulatory care claims data from mandatory health insurance. A first research question was aimed at the hypothesis that physicians with large patient lists decrease their intensity of services and bill less per patient to health insurance, and vice versa: physicians with smaller patient lists compensate for the lack of patients with additional visits and services. A second research question relates to the fact that several cantons are allowing physicians to directly dispense drugs to patients ('self-dispensation' whereas other cantons restrict such direct sales to emergencies only. This second question was based on the assumption that patterns of rescheduling patients for consultations may differ across channels of dispensing prescription drugs and therefore the hypothesis of different consultation costs in this context was investigated. Methods Complete claims data paid for by mandatory health insurance of all Swiss physicians in own practices were analyzed for the years 2003-2007. Medical specialties were pooled into six main provider types in ambulatory care: primary care, pediatrics, gynecology & obstetrics, psychiatrists, invasive and non-invasive specialists. For each provider type, regression models at the physician level were used to analyze the relationship between the number of patients treated and the total sum of treatment cost reimbursed by mandatory health insurance. Results The results show non-proportional relationships between patient numbers and total sum of treatment cost for all provider types involved implying that treatment costs per patient increase with higher practice size. The related additional costs to the health system are substantial. Regions with self-dispensation had lowest treatment cost for primary care
Wilf-Miron, R; Lewenhoff, I; Benyamini, Z; Aviram, A
The development of a medical risk management programme based on the aviation safety approach and its implementation in a large ambulatory healthcare organisation is described. The following key safety principles were applied: (1) errors inevitably occur and usually derive from faulty system design, not from negligence; (2) accident prevention should be an ongoing process based on open and full reporting; (3) major accidents are only the "tip of the iceberg" of processes that indicate possi...
Renata Laszlo Torres
Full Text Available Objective To describe the profile of Hospitalizations by Amulatory Care Sensitive Conditions (HACSC, in the Municipality of Cotia, from 2008 to 2012. Method ecological, exploratory, longitudinal study with a quantitative approach. Data on HACSC, by age group and sex, were obtained from the Department of the Unified Health System. For data analysis descriptive statistics were used. Results During the period, there were 46,676 admissions, excluding deliveries, 7,753 (16.61% by HACSC. The main causes were cerebrovascular diseases, 16.96%, heart failure, 15.50%, hypertension, 10.80% and infection of the kidney and urinary tract, 10.51%. Regarding gender, HACSC occurred predominantly in males. There was a greater number of HACSC at extreme age ranges, especially in the elderly. Conclusion Chronic diseases predominate among the leading causes of HACSC and there was no significant difference between sex.
Boesby, Lene; Thijs, Lutgarde; Elung-Jensen, Thomas;
Arterial stiffness contributes to the increased cardiovascular risk in patients with chronic kidney disease (CKD). Reproducible and easily obtainable indices of arterial stiffness are needed in order to monitor therapeutic strategies. The ambulatory arterial stiffness index (AASI) has been proposed...... as such a marker. The present study investigated the day-to-day reproducibility of AASI in CKD stage 2-5 and its relationship with other markers of arterial stiffness as well as with kidney function....
Carlos F. Lerner
Full Text Available Background: In resident primary care continuity clinics, at the end of each academic year, continuity of care is disrupted when patients cared for by the graduating class are redistributed to other residents. Yet, despite the recent focus on the transfers of care between resident physicians in inpatient settings, there has been minimal attention given to patient care transfers in academic ambulatory clinics. We sought to elicit the views of pediatric residents regarding year-end patient handoffs in a pediatric resident continuity clinic.Methods: Residents assigned to a continuity clinic of a large pediatric residency program completed a questionnaire regarding year-end transfers of care.Results: Thirty-one questionnaires were completed out of a total 45 eligible residents (69% response. Eighty seven percent of residents strongly or somewhat agreed that it would be useful to receive a written sign-out for patients with complex medical or social issues, but only 35% felt it would be useful for patients with no significant issues. Residents more frequently reported having access to adequate information regarding their new patients’ medical summary (53% and care plan (47% than patients’ functional abilities (30%, social history (17%, or use of community resources (17%. When rating the importance of receiving adequate sign-out in each those domains, residents gave most importance to the medical summary (87% of residents indicating very or somewhat important and plan of care (84%. Residents gave less importance to receiving sign-out regarding their patients’ functional abilities (71% social history (58%, and community resources (58%. Residents indicated that lack of access to adequate patient information resulted in additional work (80%, delays or omissions in needed care (56%, and disruptions in continuity of care (58%.Conclusions: In a single-site study, residents perceive that they lack adequate information during year-end patient transfers
Patterson, Emily S.; Lowry, Svetlana Z.; Ramaiah, Mala; Gibbons, Michael C.; Brick, David; Calco, Robert; Matton, Greg; Miller, Anne; Makar, Ellen; Ferrer, Jorge A.
Introduction: Human factors workflow analyses in healthcare settings prior to technology implemented are recommended to improve workflow in ambulatory care settings. In this paper we describe how insights from a workflow analysis conducted by NIST were implemented in a software prototype developed for a Veteran’s Health Administration (VHA) VAi2 innovation project and associated lessons learned. Methods: We organize the original recommendations and associated stages and steps visualized in process maps from NIST and the VA’s lessons learned from implementing the recommendations in the VAi2 prototype according to four stages: 1) before the patient visit, 2) during the visit, 3) discharge, and 4) visit documentation. NIST recommendations to improve workflow in ambulatory care (outpatient) settings and process map representations were based on reflective statements collected during one-hour discussions with three physicians. The development of the VAi2 prototype was conducted initially independently from the NIST recommendations, but at a midpoint in the process development, all of the implementation elements were compared with the NIST recommendations and lessons learned were documented. Findings: Story-based displays and templates with default preliminary order sets were used to support scheduling, time-critical notifications, drafting medication orders, and supporting a diagnosis-based workflow. These templates enabled customization to the level of diagnostic uncertainty. Functionality was designed to support cooperative work across interdisciplinary team members, including shared documentation sessions with tracking of text modifications, medication lists, and patient education features. Displays were customized to the role and included access for consultants and site-defined educator teams. Discussion: Workflow, usability, and patient safety can be enhanced through clinician-centered design of electronic health records. The lessons learned from implementing
Cavalcante, Danyelle Monteiro; Oliveira, Maria Regina Fernandes de; Rehem, Tânia Cristina Morais Santa Bárbara
This study analyzes hospitalizations due to ambulatory care-sensitive conditions with a focus on infectious and parasitic diseases (IPDs) and validates the Hospital Information System, Brazilian Unified National Health System (SIH/SUS) for recording hospitalizations due to ambulatory care-sensitive conditions in a hospital in the Federal District, Brazil, in 2012. The study estimates the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the SIH for recording hospitalizations due to ambulatory care-sensitive conditions, with the patient's medical file as the gold standard. There were 1,604 hospitalizations for hospitalizations due to ambulatory care-sensitive conditions (19.6%, 95%CI: 18.7-20.5), and the leading IPDs were renal and urinary tract infection, infection of the skin and subcutaneous tissue, and infectious gastroenteritis. IPDs were the leading cause of hospitalization in the 20 to 29-year age bracket and caused 28 deaths. Sensitivity was 70.1% (95%CI: 60.5-79.7), specificity 88.4% (95%CI: 85.6-91.2), PPV = 51.7% (95%CI: 42.7-60.7), and NPV = 94.3% (95%CI: 92.2-96.4). The findings for admissions due to ACSCs in this hospital were similar to those of other studies, featuring admissions for IPDs. The SIH/SUS database was more specific than sensitive. PMID:27027457
Mansfield Richard J
Full Text Available Abstract Background Although shoulder pain is a commonly encountered problem in primary care, there are few studies examining its presenting characteristics and clinical management in this setting. Methods We performed secondary data analysis of 692 office visits for shoulder pain collected through the National Ambulatory Medical Care Survey (Survey years 1993–2000. Information on demographic characteristics, history and place of injury, and clinical management (physician order of imaging, physiotherapy, and steroid intraarticular injection were examined. Results Shoulder pain was associated with an injury in one third (33.2% (230/692 of office visits in this population of US primary care physicians. Males, and younger adults (age ≤ 52 more often associated their shoulder pain with previous injury, but there were no racial differences in injury status. Injury-related shoulder pain was related to work in over one-fifth (21.3% (43/202 of visits. An x-ray was performed in 29.0% (164/566 of office visits, a finding that did not differ by gender, race, or by age status. Other imaging (CT scan, MRI, or ultrasound was infrequently performed (6.5%, 37/566. Physiotherapy was ordered in 23.9% (135/566 of visits for shoulder pain. Younger adults and patients with a history of injury more often had physiotherapy ordered, but there was no significant difference in the ordering of physiotherapy by gender or race. Examination of the use of intraarticular injection was not possible with this data set. Conclusion These data from the largest sample of patients with shoulder pain presenting to primary care settings offer insights into the presenting characteristics and clinical management of shoulder pain at the primary care level. The National Ambulatory Medical Care Survey is a useful resource for examining the clinical management of specific symptoms in U.S. primary care offices.
Terasaki, Genji; Ahrenholz, Nicole Chow; Haider, Mahri Z
Refugees share a common experience of displacement from their country of origin, migration, and resettlement in an unfamiliar country. More than 17 million people have fled their home countries due to war, generalized violence, and persecution. US primary care physicians must care for their immediate and long-term medical needs. Challenges include (1) language and cultural barriers, (2) high rates of mental health disorders, (3) higher prevalence of latent infections, and (4) different explanatory models for chronic diseases. This article discusses management strategies for common challenges that arise in the primary care of refugees. PMID:26320045
Ständer, S; Ständer, H F; Steinke, S; Bruland, P; Dugas, M; Augustin, M
Chronic pruritus is a highly prevalent, multifactorial symptom requiring extensive diagnostics, treatment and consideration of accompanying symptoms (reduced quality of life, sleep disorders, psychic factors). Patient care is thus complex and requires consideration of individual treatment goals. Patients indicate their wish for a symptom-free life an explanation of the causes and a trustful physician-patient relationship. The targeted use of questionnaires is thus advisable in order to structurally survey the history, pruritus intensity, quality of life and treatment progression. Nevertheless, there are many administrative and economical hurdles in the health care system to overcome in order to provide patients with chronic pruritus the best possible care, also per the recommended guidelines. The development of specialized centers and training courses for medical practitioners is thus urgently needed. PMID:27316924
Margolis, Peter A; Peterson, Laura E.; Seid, Michael
Despite significant gains by pediatric collaborative improvement networks, the overall US system of chronic illness care does not work well. A new paradigm is needed: a Collaborative Chronic Care Network (C3N). A C3N is a network-based production system that harnesses the collective intelligence of patients, clinicians, and researchers and distributes the production of knowledge, information, and know-how over large groups of people, dramatically accelerating the discovery process. A C3N is a...
Le, Tuan K; Chang, Mi; Nelson, Craig; Sortais, Julie Ann; Chand, Pushkar; Tallman, Karen
The authors randomly assigned patients with Stage 4 or 5 chronic kidney disease who had not yet begun renal dialysis to 1 of 2 groups. The test group received an additional nephrology consult with an interdisciplinary team and reported help in forming a treatment plan, felt well understood, and had the opportunity to thoroughly discuss questions. They had a decrease in beginning dialysis, clinic visits, hospital admissions, days hospitalized, and emergency room visits.
Tripodoro, Vilma A; Rynkiewicz, María C; Llanos, Victoria; Padova, Susana; De Lellis, Silvina; De Simone, Gustavo
About 75% of population will die from one or more chronic progressive diseases. From this projection WHO urged countries to devise strategies for strengthening palliative treatment as part of comprehensive care. In Catalonia, Spain, direct measurement of the prevalence of these patients with NECPAL CCOMS-ICO© tool was 1.5% of the population. This tool is an indicative, not dichotomous, quali-quantitative multifactorial evaluation to be completed by the treating physician. In Argentina there is no information on these patients. Our goal was to explore and characterize the proportion of chronically ill patients in palliative care needs, by NECPAL CCOMS-ICO© tool, in an accessible population of the City of Buenos Aires. General hospitals of the Health Region 2 (Piñero, álvarez and Santojanni) and its program areas were surveyed. In Health Region 1, we surveyed the Udaondo gastroenterology hospital. A total of 53 physicians (704 patients) were interviewed. It was identified that 29.5% of these patients were affected by advanced chronic diseases; 72.1% of them were NECPAL positive, younger (median 64) than in others studies, and more than 98% presented high levels of comorbidity. Palliative care demand (31.4%) and needs (52.7%) were recorded. Specific indicators of fragility, progression, severity and kind of chronic disease were described. The main finding was to identify, with an instrument not based on mortality that, in Buenos Aires City, 1 in 3 patients with chronic diseases could die in the next year and had palliative care needs. PMID:27295702
Piette, J. D.; Moos, R.H.
OBJECTIVE: To examine whether patients admitted for treatment of a myocardial infarction (MI) who live farther from their source of care are less likely to be followed in an outpatient clinic, and whether patients who receive follow-up care are less likely to die or to have a subsequent acute care admission. DATA SOURCE: Department of Veterans Affairs (VA) databases to identify a national sample of 4,637 MI patients discharged in 1992, their use of care, and vital status within the subsequent...
Bansler, Jørgen Peter; Havn, Erling C.; Mønsted, Troels
This paper reports preliminary findings from an ongoing research project on the development of IT support for communication and information sharing across institutional and professional boundaries within the Danish healthcare system. The project focuses on the treatment of patients with implanted...... ICDs (implantable cardioverter-defibrillator). These are chronic patients who usually see several different healthcare providers on a regular basis. The main findings so far are: (1) Most of the data produced and recorded as part of the care process are context-specific and often difficult to interpret...
Simon Steven R; Kleinman Kenneth P; Soto Carlos M
Abstract Background Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record. Metho...
Sive, Jonathan; Ardeshna, Kirit M; Cheesman, Simon; le Grange, Franel; Morris, Stephen; Nicholas, Claire; Peggs, Karl; Statham, Paula; Goldstone, Anthony H
Since 2005, University College London Hospital (UCLH) has operated a hotel-based Ambulatory Care Unit (ACU) for hematology and oncology patients requiring intensive chemotherapy regimens and hematopoietic stem cell transplants. Between January 2005 and 2011 there were 1443 patient episodes, totaling 9126 patient days, with increasing use over the 6-year period. These were predominantly for hematological malignancy (82%) and sarcoma (17%). Median length of stay was 5 days (range 1-42), varying according to treatment. Clinical review and treatment was provided in the ACU, with patients staying in a local hotel at the hospital's expense. Admission to the inpatient ward was arranged as required, and there was close liaison with the inpatient team to preempt emergency admissions. Of the 523 unscheduled admissions, 87% occurred during working hours. An ACU/hotel-based treatment model can be safely used for a wide variety of cancers and treatments, expanding hospital treatment capacity, and freeing up inpatient beds for those patients requiring them. PMID:22591143
Brod, Meryl; Rousculp, Matthew; Cameron, Ann
Background The challenge of understanding factors influencing compliance with injectable treatments is critical as injectable biologics/medications become more common. Objective Understanding compliance issues for long term self-injectable treatments, using a chronic condition (osteoporosis) as a model. Research design A qualitative study to generate hypotheses regarding compliance issues for self-injectable treatments. Semi-structured interview guides were developed and data collected from p...
Awan, Saima; Samokhvalov, Andriy V; Aleem, Nadia; Hendershot, Christian S; Irving, Julie Anne; Kalvik, Anne; Lefebvre, Lisa; Le Foll, Bernard; Quilty, Lena; Voore, Peter
Integrated care pathways (ICPs) provide an approach for delivering evidence-based treatment in a hospital setting. This column describes the development and pilot implementation in a clinical setting of an ICP for patients with concurrent major depressive disorder and alcohol dependence at the Centre for Addiction and Mental Health (CAMH), an academic tertiary care hospital, in Toronto, Canada. The ICP methodology includes evidence reviews, knowledge translation, process reengineering, and change management. Pilot results indicate high patient satisfaction, evidence of symptom improvement, and excellent retention. PMID:26278235
De Young, M
Research on the effects of pharmacist-patient communication that appeared in the pharmacy literature between 1969 and 1994 is reviewed. The terms patients education and patient counseling were used in identifying relevant research. Many authors used these terms interchangeably; also, the terms counseling and consultation often were not clearly defined. Studies of pharmacists' history-taking in institutional settings and of other communication with patients in ambulatory care settings were examined by decade. The research questions, theories, methods, results, and limitations were analyzed. More than 30 studies examined the effect of pharmacists' communication on patient outcomes, primarily knowledge and medication compliance; generally, the results suggested that pharmacists' communication led to increased knowledge and compliance. A few researchers raised concerns about patients' knowledge as an indicator of effective communication by pharmacists, and in the 1980s a few suggested that better medication compliance could be associated with the time and attention given to patients rather than the informational content of the interaction. Little was reported about the communication theories or models on which the studies were based, and there was little indication in most studies that patients' ideas about their therapy were considered. Often, the numbers of patients and pharmacists were small, and the pharmacists may have had training or motivation exceeding that of the average practitioner. In studies of pharmacists' versus physicians' history-taking, the physicians were not well described; their involvement and their approach may not have been comparable to those of the pharmacists. Before 1990, a few researchers had examined outcomes such as pulmonary function and control of diabetes. In the 1990s, more researchers looked at outcomes such as medication-related problems and use of health care resources. The research indicated that pharmacists can increase patients
Paula W. Yoon, ScD, MPH
Full Text Available IntroductionClinical preventive services can detect diseases early, when they are most treatable, but these services may not be provided as recommended. Assessing the provision of services to patients at risk for cardiovascular disease (CVD could help identify disparities and areas for improvement.MethodsWe used data on patient visits (n = 21,261 from the National Ambulatory Medical Care Survey, 2005-2006, and classified patients with hypertension, hyperlipidemia, obesity, or diabetes as being at risk for CVD. We assessed differences in the provision of preventive services offered to patients who were and who were not at risk for CVD. Further, for those at risk, we compared the demographic characteristics of those who had and who had not been offered services.ResultsPatients at risk for CVD received significantly more preventive services compared with those not at risk. For patients at risk for CVD, aspirin therapy was more likely to be recommended to those aged 65 years or older than those aged 45 to 64 years and to men than women. Cholesterol screening was more likely for men and was less likely for patients with Medicare/Medicaid or no insurance than for patients who were insured. Rates of counseling for diet and nutrition, weight reduction, and exercise were low overall, but younger patients received these services more than older patients did.ConclusionPatients at risk for CVD are not all receiving the same level of preventive care, suggesting the need to clarify clinical practice guidelines and provide clinicians with education and support for more effective lifestyle counseling.
Veenhuizen Ruth B
Full Text Available Abstract Background A multidisciplinary outpatient department was set up in the northern part of the Netherlands because of a local lack of adequate treatment and care for Huntington's disease (HDpatients. Outreaching multidisciplinary care is a novel way to optimise functioning and quality of life of HD patients. The vast majority of patients want to stay home as long as possible. Huntington's disease is a devastating neurodegenerative disorder leading to complete disability and long term residence in a specialised institution. In this paper we outline this new type of treatment and give the results of 1.5 year, we also present the results of an inquiry on the appreciation of the working method. Methods In the first project half (1.5 yr 28 patients were seen as had been anticipated. The multidisciplinary team consisting of an institutional physician, a psychologist, a speech and language therapist, a social worker, an occupational therapist and a case manager, assesses the stage of the disease and formulates, coordinates and implements the individual care and treatment plan in the home situation. After 1.5 year a questionnaire on the appreciation of the department was sent to patients, caregivers, healthcare professionals, the lay organisation and Dutch "experts in the field". Results For the 28 HD patients a total of 242 problems and actions were verbalised in the care plan, which was accepted by the majority of the patients. Especially informal caregivers, the lay organisation and the Dutch "experts in the field" were enthusiastic on the outreaching and multidisciplinary nature of the department. The verdict over the continuance of the clinic was positive and unanimous. Conclusions We concluded that coordinating outreaching multidisciplinary care from an outpatient clinic into the dwelling place of the patient is feasible and appreciated.
Laurent Billot; Kate Corcoran; Alina McDonald; Gawaine Powell-Davies; Anne-Marie Feyer
The New South Wales Health (NSW Health) Chronic Disease Management Program (CDMP) delivers interventions to adults at risk of hospitalisation for five target chronic conditions that respond well to ambulatory care: diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, and coronary artery disease. The intervention consists of two main components: (1) care coordination across sectors (acute, ambulatory, and community care from both public and private sectors) ...
da Silva, V L; Steinberg, B
The tool presented here is useful in analyzing the constraints and capabilities of a health care telephone service. It also provides a systematic method for assessing systems problems. As part of our analysis, we recommended that the manager implement the following steps. First, the manager determines whether the driving force on the unit is continuity of care by an individual provider or consistency of response. This focus directly affects how the unit's telephone service can be best organized (i.e., decentralized or centralized) and clarifies the factors most needed for success. For example, to function effectively and efficiently, a centralized phone service needs strong provider-endorsed protocols. Second, the manager should carefully examine neutral constraint factors to determine methods to transform these constraints into capabilities, such as planning for extra staff or office hours (or both) during influenza season. Planning for extra hours or staff depends largely on whether budget and resource planning is done in advance and whether value is placed on customer access and satisfaction during peak demand periods. The manager must next determine whether the service delivery format (centralized or decentralized) is consistent with the force field analysis findings. If the findings are not consistent, can the analysis present a compelling argument for using the opposite approach? Finally, the manager must create a plan of action for minimizing the constraints revealed and maximizing existing capabilities to achieve the overall goal of excellent phone service. The process of analysis and creating a plan of action is an excellent opportunity to involve staff, providers, and administrators in efforts to achieve better health care telephone service for all customers. PMID:10112997
Simon Steven R
Full Text Available Abstract Background Documentation in the medical record facilitates the diagnosis and treatment of patients. Few studies have assessed the quality of outpatient medical record documentation, and to the authors' knowledge, none has conclusively determined the correlates of chart documentation. We therefore undertook the present study to measure the rates of documentation of quality of care measures in an outpatient primary care practice setting that utilizes an electronic medical record. Methods We reviewed electronic medical records from 834 patients receiving care from 167 physicians (117 internists and 50 pediatricians at 14 sites of a multi-specialty medical group in Massachusetts. We abstracted information for five measures of medical record documentation quality: smoking history, medications, drug allergies, compliance with screening guidelines, and immunizations. From other sources we determined physicians' specialty, gender, year of medical school graduation, and self-reported time spent teaching and in patient care. Results Among internists, unadjusted rates of documentation were 96.2% for immunizations, 91.6% for medications, 88% for compliance with screening guidelines, 61.6% for drug allergies, 37.8% for smoking history. Among pediatricians, rates were 100% for immunizations, 84.8% for medications, 90.8% for compliance with screening guidelines, 50.4% for drug allergies, and 20.4% for smoking history. While certain physician and patient characteristics correlated with some measures of documentation quality, documentation varied depending on the measure. For example, female internists were more likely than male internists to document smoking history (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.27 – 2.83 but were less likely to document drug allergies (OR, 0.51; 95% CI, 0.35 – 0.75. Conclusions Medical record documentation varied depending on the measure, with room for improvement in most domains. A variety of
DiPiero, Albert; Sanders, David G
Fee-for-service is more than a payment method; it defines the method of care. Fee-for-condition—a payment method that rewards superior results and encourages innovation—could greatly improve care for chronic conditions
Enhancing activities of daily living of chronic stroke patients in primary health care by modified constraint-induced movement therapy (HOMECIMT): study protocol for a cluster randomized controlled trial
Barzel, Anne; Ketels, Gesche; Tetzlaff, Britta; Krüger, Heike; Haevernick, Kerstin; Daubmann, Anne; Wegscheider, Karl; Scherer, Martin
Background Stroke leads to constant rehabilitation needs even at the chronic stage. However, although many stroke patients receive physical or occupational therapy in primary health care, treatment prescriptions do not generally specify therapeutic goals; in particular, participation is not established as an explicit therapeutic goal in the ambulatory setting. The primary aim of this study is to evaluate the efficacy of a therapy regimen for chronic stroke patients (modified ‘constraint-induc...
Fermo JD; Whitley HP; Thompson AM; Ragucci KR
Until recently, Prothrombin Time/International Normalized Ratio (PT/INR) measurements have typically been used to monitor patients on warfarin through institutional laboratories via venous puncture. The Point-of-Care Testing (POCT) device has revolutionized the patient care process by allowing for laboratory testing outside of the central laboratory. Objective: To analyze humanistic and clinical outcomes in patients currently treated with warfarin and monitored through a pharmacist-managed an...
Full Text Available This is one of the first studies to (1 describe the out-of-hospital burden of influenza-like-illness (ILI and clinically diagnosed flu, also for patients not seeking professional medical care, (2 assess influential background characteristics, and (3 formally compare the burden of ILI in patients with and without a clinical diagnosis of flu. A general population sample with recent ILI experience was recruited during the 2011-2012 influenza season in Belgium. Half of the 2250 respondents sought professional medical care, reported more symptoms (especially more often fever, a longer duration of illness, more use of medication (especially antibiotics and a higher direct medical cost than patients not seeking medical care. The disease and economic burden were similar for ambulatory ILI patients, irrespective of whether they received a clinical diagnosis of flu. On average, they experienced 5-6 symptoms over a 6-day period; required 1.6 physician visits and 86-91% took medication. An average episode amounted to €51-€53 in direct medical costs, 4 days of absence from work or school and the loss of 0.005 quality-adjusted life-years. Underlying illness led to greater costs and lower quality-of-life. The costs of ILI patients with clinically diagnosed flu tended to increase, while those of ILI patients without clinically diagnosed flu tended to decrease with age. Recently vaccinated persons experienced lower costs and a higher quality-of-life, but this was only the case for patients not seeking professional medical care. This information can be used directly to evaluate the implementation of cost-effective prevention and control measures for influenza. In particular to inform the evaluation of more widespread seasonal influenza vaccination, including in children, which is currently considered by many countries.
Bilcke, Joke; Coenen, Samuel; Beutels, Philippe
This is one of the first studies to (1) describe the out-of-hospital burden of influenza-like-illness (ILI) and clinically diagnosed flu, also for patients not seeking professional medical care, (2) assess influential background characteristics, and (3) formally compare the burden of ILI in patients with and without a clinical diagnosis of flu. A general population sample with recent ILI experience was recruited during the 2011-2012 influenza season in Belgium. Half of the 2250 respondents sought professional medical care, reported more symptoms (especially more often fever), a longer duration of illness, more use of medication (especially antibiotics) and a higher direct medical cost than patients not seeking medical care. The disease and economic burden were similar for ambulatory ILI patients, irrespective of whether they received a clinical diagnosis of flu. On average, they experienced 5-6 symptoms over a 6-day period; required 1.6 physician visits and 86-91% took medication. An average episode amounted to €51-€53 in direct medical costs, 4 days of absence from work or school and the loss of 0.005 quality-adjusted life-years. Underlying illness led to greater costs and lower quality-of-life. The costs of ILI patients with clinically diagnosed flu tended to increase, while those of ILI patients without clinically diagnosed flu tended to decrease with age. Recently vaccinated persons experienced lower costs and a higher quality-of-life, but this was only the case for patients not seeking professional medical care. This information can be used directly to evaluate the implementation of cost-effective prevention and control measures for influenza. In particular to inform the evaluation of more widespread seasonal influenza vaccination, including in children, which is currently considered by many countries. PMID:25032688
Bilcke, Joke; Coenen, Samuel; Beutels, Philippe
This is one of the first studies to (1) describe the out-of-hospital burden of influenza-like-illness (ILI) and clinically diagnosed flu, also for patients not seeking professional medical care, (2) assess influential background characteristics, and (3) formally compare the burden of ILI in patients with and without a clinical diagnosis of flu. A general population sample with recent ILI experience was recruited during the 2011–2012 influenza season in Belgium. Half of the 2250 respondents sought professional medical care, reported more symptoms (especially more often fever), a longer duration of illness, more use of medication (especially antibiotics) and a higher direct medical cost than patients not seeking medical care. The disease and economic burden were similar for ambulatory ILI patients, irrespective of whether they received a clinical diagnosis of flu. On average, they experienced 5–6 symptoms over a 6-day period; required 1.6 physician visits and 86–91% took medication. An average episode amounted to €51–€53 in direct medical costs, 4 days of absence from work or school and the loss of 0.005 quality-adjusted life-years. Underlying illness led to greater costs and lower quality-of-life. The costs of ILI patients with clinically diagnosed flu tended to increase, while those of ILI patients without clinically diagnosed flu tended to decrease with age. Recently vaccinated persons experienced lower costs and a higher quality-of-life, but this was only the case for patients not seeking professional medical care. This information can be used directly to evaluate the implementation of cost-effective prevention and control measures for influenza. In particular to inform the evaluation of more widespread seasonal influenza vaccination, including in children, which is currently considered by many countries. PMID:25032688
Kadu, Mudathira K; Stolee, Paul
Background The Chronic Care Model (CCM) is a framework developed to redesign care delivery for individuals living with chronic diseases in primary care. The CCM and its various components have been widely adopted and evaluated, however, little is known about different primary care experiences with its implementation, and the factors that influence its successful uptake. The purpose of this review is to synthesize findings of studies that implemented the CCM in primary care, in order to identi...
A contextual review of models for chronic care was doneto develop a context-adapted chronic care model-basedservice delivery model for chronic conditions includingdiabetes. The Philippines was used as the setting ofa low-to-middle-income country. A context-basednarrative review of existing models for chronic carewas conducted. A situational analysis was done at thegrassroots level, involving the leaders and members ofthe community, the patients, the local health system andthe healthcare providers. A second analysis making useof certain organizational theories was done to explore onimproving feasibility and acceptability of organizing carefor chronic conditions. The analyses indicated that carefor chronic conditions may be introduced, consideringthe needs of people with diabetes in particular andthe community in general as recipients of care, andthe issues and factors that may affect the healthcareworkers and the health system as providers of thiscare. The context-adapted chronic care model-basedservice delivery model was constructed accordingly.Key features are incorporation of chronic care in thehealth system＇s services; assimilation of chronic caredelivery with the other responsibilities of the healthcareworkers but with redistribution of certain tasks; andensuring that the recipients of care experience thewhole spectrum of basic chronic care that includes educationand promotion in the general population, riskidentification, screening, counseling including self-caredevelopment, and clinical management of the chroniccondition and any co-morbidities, regardless of level ofcontrol of the condition. This way, low-to-middle incomecountries can introduce and improve care for chronicconditions without entailing much additional demand ontheir limited resources.
Andrew J. Gawron
Full Text Available Introduction. Proton pump inhibitors (PPI are one of the most commonly prescribed medication classes with similar efficacy between brand name and generic PPI formulations. Aims. We determined demographic, clinical, and practice characteristics associated with brand name PPI prescriptions at ambulatory care visits in the United States. Methods. Observational cross sectional analysis using the National Ambulatory Medical Care Survey (NAMCS of all adult (≥18 yrs of age ambulatory care visits from 2006 to 2010. PPI prescriptions were identified by using the drug entry code as brand name only or generic available formulations. Descriptive statistics were reported in terms of unweighted patient visits and proportions of encounters with brand name PPI prescriptions. Global chi-square tests were used to compare visits with brand name PPI prescriptions versus generic PPI prescriptions for each measure. Poisson regression was used to determine the incidence rate ratio (IRR for generic versus brand PPI prescribing. Results. A PPI was prescribed at 269.7 million adult ambulatory visits, based on 9,677 unweighted visits, of which 53% were brand name only prescriptions. In 2006, 76.0% of all PPI prescriptions had a brand name only formulation compared to 31.6% of PPI prescriptions in 2010. Visits by patients aged 25–44 years had the greatest proportion of brand name PPI formulations (57.9%. Academic medical centers and physician-owned practices had the greatest proportion of visits with brand name PPI prescriptions (58.9% and 55.6% of visits with a PPI prescription, resp.. There were no significant differences in terms of median income, patient insurance type, or metropolitan status when comparing the proportion of visits with brand name versus generic PPI prescriptions. Poisson regression results showed that practice ownership type was most strongly associated with the likelihood of receiving a brand name PPI over the entire study period. Compared to
Berenson, Robert A; Horvath, Jane
This paper examines the ability of the current Medicare program--both traditional fee-for-service and risk-based contracting--to address the needs of beneficiaries with chronic conditions, who represent almost 80 percent of program enrollment. Grounded in indemnity insurance principles, including concerns about "moral hazard," the traditional Medicare program faces difficulty evolving to support of a chronic care model of health care practice. Although capitation may be the most desirable platform to support provision of care to beneficiaries with chronic conditions, the current structural limitations and problems faced in the Medicare+Choice program limit capitation's use at this time. PMID:14527234
Saundra H. Glover
Full Text Available Despite efforts to eliminate health disparities, racial, ethnic, and geographic groups continue lag behind their counterparts in health outcomes in the United States. The purpose of this study is to determine variation in specialty care utilization by chronic disease status. Data were extracted from the Commonwealth Fund 2006 Health Care Quality Survey (n = 2475. A stratified minority sample design was employed to ensure a representative sample. Logistic regression was used in analyses to predict specialty care utilization in the sample. Poor perceived health, minority status, and lack of insurance was associated with reduced specialty care use and chronic disease diagnosis.
U.S. Department of Health & Human Services — According to findings reported in Impact of Chronic Conditions on the Cost of Cancer Care for Medicaid Beneficiaries, published in Volume 2, Issue 4 of the Medicare...
Full Text Available The National Ambulatory Medical Care Survey collects data on office-based physician care from a nationally representative, multistage sampling scheme where the ultimate unit of analysis is a patient-doctor encounter. Patient race, a commonly analyzed demographic, has been subject to a steadily increasing item nonresponse rate. In 1999, race was missing for 17 percent of cases; by 2008, that figure had risen to 33 percent. Over this entire period, single imputation has been the compensation method employed. Recent research at the National Center for Health Statistics evaluated multiply imputing race to better represent the missing-data uncertainty. Given item nonresponse rates of 30 percent or greater, we were surprised to find many estimates’ ratios of multiple-imputation to single-imputation estimated standard errors close to 1. A likely explanation is that the design effects attributable to the complex sample design largely outweigh any increase in variance attributable to missing-data uncertainty.
Mathew J. Gregoski
Full Text Available Stress-activated gene × environment interactions may contribute to individual variability in blood pressure reductions from behavioral interventions. We investigated effects of endothelin-1 (ET-1 LYS198ASN SNP and discriminatory stress exposure upon impact of 12-week behavioral interventions upon ambulatory BP (ABP among 162 prehypertensive African American adolescents. Following genotyping, completion of questionnaire battery, and 24-hour ABP monitoring, participants were randomized to health education control (HEC, life skills training (LST, or breathing awareness meditation (BAM. Postintervention ABP was obtained. Significant three-way interactions on ABP changes indicated that among ET-1 SNP carriers, the only group to show reductions was BAM from low chronic stress environments. Among ET-1 SNP noncarriers, under low chronic stress exposure, all approaches worked, especially BAM. Among high stress exposure noncarriers, only BAM resulted in reductions. If these preliminary findings are replicated via ancillary analyses of archival databases and then via efficacy trials, selection of behavioral prescriptions for prehypertensives will be edging closer to being guided by individual's underlying genetic and environmental factors incorporating the healthcare model of personalized preventive medicine.
Brown, Crystal E; Jecker, Nancy S; Curtis, J Randall
Patients with chronic lung diseases suffer higher symptom burden, lower quality of life, and greater social isolation compared with patients with other diagnoses, such as cancer. These conditions may be alleviated by palliative care, yet palliative care is used less by patients with chronic lung disease compared with patients with cancer. Underuse is due, in part, to poor implementation of primary palliative care and inadequate referral to specialty palliative care. Lack of primary and specialty palliative care in patients with chronic lung disease falls short of the minimum standard of competent health care, and represents a disparity in health care and a social injustice. We invoke the ethical principles of justice and sufficiency to highlight the importance of this issue. We identify five barriers to implementing palliative care in patients with chronic lung disease: uncertainty in prognosis; lack of provider skill to engage in discussions about palliative care; fear of using opioids among patients with chronic lung disease; fear of diminishing hope; and perceived and implicit bias against patients with smoking-related lung diseases. We propose mechanisms for improving implementation of palliative care for patients with chronic lung disease with the goal of enhancing justice in health care. PMID:26730490
Knai, Cécile; Nolte, Ellen; Brunn, Matthias; Elissen, Arianne; Conklin, Annalijn; Pedersen, Janice Pedersen; Brereton, Laura; Erler, Antje; Frølich, Anne; Flamm, Maria; Fullerton, Birgitte; Jacobsen, Ramune; Krohn, Robert; Saz-Parkinson, Zuleika; Vrijhoef, Bert; Chevreul, Karine; Durand-Zaleski, Isabelle; Farsi, Fadila; Sarría-Santamera, Antonio; Soennichsen, Andreas
The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries....
Full Text Available Chronic care consists of a sequence of actions to treat a specific clinical disorder over time as a function of the ways in which illness progresses and patients respond to management actions. Outcomes depend on physicians' skills to select the actions best suited for their patients and competent self-management. This paper presents the architecture of an intelligent partner system (IPS, which helps to provide doctors with relevant data and skills and empowers chronically ill patients with the information and confidence to manage their health wisely. The services of this intelligent system are presented as 'therapies' for the information-processing 'pathologies' associated with traditional chronic illness care.
Full Text Available Peritoneal dialysis offers several advantages such as better clearance of intermediate/large molecules and better preservation of renal residual function when compared with hemodialysis. However, dialysis adequacy is one of the subjects of concern of this modality. There are some drugs that are capable of influencing solute transport in the peritoneum, such as acetyle co-enzyme inhibitors (ACE-I medications and calcium channel blockers. Captopril and Verapamil are often mentioned, but their use has shown varying conclusions and initial studies were performed with the intra-peritoneal administration of these drugs and there are only a few studies on the effect of the oral administration of these drugs. This study was undertaken with the aim to evaluate the effects of oral administration of Verapamil and Enalapril among continuous ambulatory peritoneal dialysis (CAPD patients. The results of this study showed that Verapamil and Enalapril do not have any effects on glucose, creatinine, sodium, potassium and urea clearance (during the 4-h peritoneal equilibration test (PET test. However, it was shown that Enalapril significantly increased the peritoneal urea Kt/V and caused a meaningful decrease in the diastolic and mean blood pressures. Therefore, we feel that Enalapril may be administered as an anti-hypertensive medication of choice in CAPD patients, which can also result in better dialysis adequacy. However, further studies with larger sample sizes are needed in the future.
Ravn, Iben M; Frederiksen, Kirsten; Beedholm, Kirsten
This article reports on the results of a Fairclough-inspired critical discourse analysis aiming to clarify how chronically ill patients are presented in contemporary Danish chronic care policies. Drawing on Fairclough's three-dimensional framework for analyzing discourse, and using Dean's concepts of governmentality as an interpretative lens, we analyzed and explained six policies published by the Danish Health and Medicines Authority between 2005 and 2013. The analysis revealed that discourses within the policy vision of chronic care consider chronically ill patients' active role, lifestyle, and health behavior to be the main factors influencing susceptibility to chronic diseases. We argue that this discursive construction naturalizes a division between people who can actively manage responsible self-care and those who cannot. Such discourses may serve the interests of those patients who are already activated, while others remain subjugated to certain roles. For example, they may be labeled as "vulnerable." PMID:25662943
Daiane Medeiros da Silva; Hérika Brito Gomes de Farias; Tereza Cristina Scatena Villa; Lenilde Duarte de Sá; Maria Eugênia Firmino Brunello; Jordana Almeida Nogueira
Abstract OBJECTIVE: To analyze the care provided to tuberculosis cases in primary health care services according to the elements of the Chronic Care Model. METHOD: Cross-sectional study conducted in a capital city of the northeastern region of Brazil involving 83 Family Health Strategy professionals.A structured tool adapted to tuberculosis-related care in Brazil was applied.Analysis was based on the development of indicators with capacity to produce care varying between limited and optimum...
Martin Carmel M; Peterson Chris; Robinson Rowena; Sturmberg Joachim P
Abstract Background Chronic disease is a major global challenge. However, chronic illness and its care, when intruding into everyday life, has received less attention in Asia Pacific countries, including Australia, who are in the process of transitioning to chronic disease orientated health systems. Aim The study aims to examine experiences of chronic illness before and after the introduction of Australian Medicare incentives for longer consultations and structured health assessments in gener...
The shift in the site of service delivery from inpatient and institutional to ambulatory and community settings has been prompted by concerns over cost and the prospect for improving the quality of life. In response to these concerns, Medicare has implemented several demonstrations that emphasize ambulatory and community-based services. In this issue, articles are presented on four demonstrations, which focus on the extent to which coordinated care models reduce health care costs, and the cos...
Milani, Richard V; Lavie, Carl J
Chronic disease has become the great epidemic of our times, responsible for 75% of total health care costs and the majority of deaths in the US. Our current delivery model is poorly constructed to manage chronic disease, as evidenced by low adherence to quality indicators and poor control of treatable conditions. New technologies have emerged that can engage patients and offer additional modalities in the treatment of chronic disease. Modifying our delivery model to include team-based care in concert with patient-centered technologies offers great promise in managing the chronic disease epidemic. PMID:25460529
Purpose: False-negative results are obtained in approx. 20 % of prostate cancer (PCa) patients (pts) at initial systematic transrectal biopsy (Bx), in particular when digital rectal examination (DRE) or transrectal ultrasound (TRUS) is negative. The aim of this study was to assess whether MR endorectal imaging of the prostate in a multi-reader ambulatory care setting may assist in patient selection for re-biopsy. Materials and Methods: 115 consecutive pts with persistent PSA elevation, negative Bx, DRE and TRUS were examined using T2w axial and coronal and T1w axial sequences for tumor diagnosis. MR images were prospectively read as tumor-suspicious or tumor-negative by the MR radiologist on duty. Additionally, a retrospective readout of a prostate MR expert and an abdominal imaging fellowship-trained radiologist was performed to evaluate the effect of the reader's experience on tumor detection. Imaging findings were compared to the results of the repeat Bx (61 pts) or the clinical course of at least two years. Results: For the prospective reading, the sensitivity of MRI was 83 %, the specificity was 69 %, the PPV was 33 % and the NPV was 96 %. ROC analysis revealed a significantly better performance of the prostate MR imaging expert compared to the abdominal imaging radiologist (area under ROC 0.88 vs. 0.66, p < 0.001). Based on the prospective reading, a pre-test probability for PCa of 17.4 % as in our study can be reduced to 5 % when obtaining a tumor-negative result in MRI. Conclusion: MR imaging in a multi-reader ambulatory care setting assists in patient selection for re-biopsy. Reducing the post-test probability for PCa to 5 % allows for further follow-up instead of re-biopsy in MR tumor-negative patients. Specific training and experience improve tumor detection in prostate MR imaging. (orig.)
Stewart Allison; Dowden Michelle; Robinson Gary; Cunningham Joan; Bailie Ross; Si Damin; Connors Christine; Weeramanthri Tarun
Abstract Background Indigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from chronic illness such as diabetes, renal disease and cardiovascular disease. Improving the understanding of how Indigenous primary care systems are organised to deliver chronic illness care will inform efforts to improve the quality of care for Indigenous people. Methods This cross-sectional study was conducted in 12 Indigenous communities in Australia's Northern Territ...
Full Text Available Abstract Background Knowledge translation (KT is an imperative in order to implement research-based and contextualized practices that can answer the numerous challenges of complex health problems. The Chronic Care Model (CCM provides a conceptual framework to guide the implementation process in chronic care. Yet, organizations aiming to improve chronic care require an adequate level of organizational readiness (OR for KT. Available instruments on organizational readiness for change (ORC have shown limited validity, and are not tailored or adapted to specific phases of the knowledge-to-action (KTA process. We aim to develop an evidence-based, comprehensive, and valid instrument to measure OR for KT in healthcare. The OR for KT instrument will be based on core concepts retrieved from existing literature and validated by a Delphi study. We will specifically test the instrument in chronic care that is of an increasing importance for the health system. Methods Phase one: We will conduct a systematic review of the theories and instruments assessing ORC in healthcare. The retained theoretical information will be synthesized in a conceptual map. A bibliography and database of ORC instruments will be prepared after appraisal of their psychometric properties according to the standards for educational and psychological testing. An online Delphi study will be carried out among decision makers and knowledge users across Canada to assess the importance of these concepts and measures at different steps in the KTA process in chronic care. Phase two: A final OR for KT instrument will be developed and validated both in French and in English and tested in chronic disease management to measure OR for KT regarding the adoption of comprehensive, patient-centered, and system-based CCMs. Discussion This study provides a comprehensive synthesis of current knowledge on explanatory models and instruments assessing OR for KT. Moreover, this project aims to create more
Patil, NG; Leung, GKK; Chan, DCW; Fong, DHF; Leung, JYY
Objective: To review the current evidence on the mechanism of actions and clinical applications of maggot debridement therapy. Data sources: Literature search of PubMed and Medline was performed up to January 2007. Study selection: Original and major review articles related to maggot debridement therapy were reviewed. Key words used in the literature search were 'maggot debridement therapy', 'wound healing', and 'chronic wound management'. Data extraction: All relevant English and Chinese art...
Stellefson, Michael; Dipnarine, Krishna; Stopka, Christine
Introduction The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. Methods We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academi...
Processo de cuidar do idoso em Diálise Peritoneal Ambulatorial Contínua no domicílio Proceso de cuidar del anciano, que hace Diálisis Peritoneal Ambulatorial Contínua en el domicilio Home care for the elderly undergoing Continuous Ambulatory Peritoneal Dialysis
Daniele Favaro Ribeiro
DPAC.Objectives: To describe the elders with end stage renal disease (ESRD undergoing continuous ambulatory peritoneal dialysis (CAPD, their caregivers, and the care the caregivers provide to the elders. Methods: This was a qualitative study with 9 caregivers. Data were collected through oral history. Data analysis consisted of thematic content analysis. Results: The sample consisted of 5 male and 4 female elders and all them were dependent on caregivers to change the dialysis collection bag. The mean age of the participants was 70 years. Among the caregivers, 8 of them were female with a mean age of 41.5 years and they provided 8 hours of care to the elders daily. The main theme emerging from the content analysis was "home care for the elderly undergoing continuous ambulatory peritoneal dialysis." Conclusion: Caregivers need support for the development of knowledge and skills to deal with the elders' demand of care, particularly in regard to the management of CAPD.
S. J. Showande et al.
Full Text Available This study assessed the level of compliance using three different methods: pill count, self report and peak expiratory flow rate, in asthmatic patients attending a secondary health care facility. Self report (using a pre-tested structured questionnaire, peak expiratory flow rate and pill count were used to assess patient’s compliance and identify the factors which may be responsible for non compliance. Measurement of peak expiratory flow rate and the pill count were done at two different occasions. The data obtained was analysed using descriptive statistics. The study showed that the patients were prescribed a range of one to four drugs: 54% (3 drugs, 32% (2 drugs, 8% (4 drugs and 2% (1 drug. The levels of compliance were 86.57% for self report and 83.56% for pill count (p > 0.05. Reasons given for non compliance were: apparent wellness (33.31%, forgetfulness (26.67%, cost of drugs (6.67%, dysphagia (6.67%, presence of non-disturbing symptoms (6.67%, side effects (6.67%, ignorance/fear of addiction (6.67%, perceived lack of benefit from treatment (6.67%, and lethargy towards chronic medication (6.67%. However, there was a significant difference in the readings of the peak expiratory flow rate measured at two different occasions (p < 0.05. The study showed no significant difference in the methods used to assess the level of compliance. Non compliance can be overcome by proper education of patients on the importance of complying with the administration of medication and proper usage of metered dose devices.
textabstractDisease management has emerged as a new strategy to enhance quality of care for patients suffering from chronic conditions, and to control health care costs. So far, however, the effects of this strategy remain unclear. The purpose of this thesis was to determine the core elements of disease management and to understand how they operate and interact in order to effectively evaluate disease-management programmes, particularly for patients with chronic obstructive pulmonary disease....
Sano H; Kouraba S; Ogawa R
Hitomi Sano,1 Sachio Kouraba,2 Rei Ogawa11Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan; 2Sapporo Wound Care and Anti-Aging Laboratory, Sapporo, JapanAbstract: Chronic leg ulcers are a significant health care concern. Although deep wounds are usually treated by flap transfers, the operation is invasive and associates with serious complications. Skin grafts may be a less invasive means of covering wounds. However, skin grafts cannot survive o...
Glover, Saundra H.; Edith Williams; Qiang Cheng,; Rivers, Patrick A; Hassan, Rahnuma M.; Bellinger, Jessica D.
Despite efforts to eliminate health disparities, racial, ethnic, and geographic groups continue lag behind their counterparts in health outcomes in the United States. The purpose of this study is to determine variation in specialty care utilization by chronic disease status. Data were extracted from the Commonwealth Fund 2006 Health Care Quality Survey (n = 2475). A stratified minority sample design was employed to ensure a representative sample. Logistic regression was used in analyses to pr...
Fraser, Simon; Blakeman, Thomas
Simon DS Fraser,1 Tom Blakeman2 1Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, Southampton General Hospital, University of Southampton, Southampton, 2National Institute for Health Research Collaboration for Leadership in Applied Health Research Greater Manchester, Centre for Primary Care, Institute of Population Health, The University of Manchester, Manchester, UK Abstract: Chronic kidney disease (CKD) is an important and common noncommunicable condition globally...
Claire van Deventer
Full Text Available Background: Chronic illnesses are a significant burden to the health services in South Africa. There is a specific national health plan whereby chronically ill patients who are acceptably controlled should be managed at clinic level. The perception has emerged that the management of primary care has not been optimal in the Southern District of the North West Province. This provided the motivation to initiate this research, namely consideration of chronic patient care at clinics in the North West Province of South Africa.Method: A cross-sectional descriptive study was carried out at four randomly selected clinics covering four sub-districts in the Southern District (North West Province. This was done using charts and registers at the clinics. Inclusion criteria were patients older than 18, and presenting with the following chronic illnesses: asthma/chronic obstructive airways disease (COAD, hypertension, diabetes and epilepsy. The major focus areas were the regular assessment of the patients, the level of control of the illness and the use of the Essential Drugs List and Standard Treatment Guidelines (EDL/STG.Results: In the cases of all the chronic illnesses it was found that regular assessments were poorly done, with asthma (peak flow measurements being the most poorly done. Control was generally less than 50% for all the illnesses, although the EDL was followed fairly well by the personnel at the clinics.Conclusion: In the light of the burden of chronic illness the results give cause for great concern about the quality of care for chronically ill patients, and reasons were sought for some of the poor results. A subsequent decision was taken to carry out comprehensive quality improvement projects on each of the illnesses over the following five years.
Willemse, Evi; Adriaenssens, Jef; Dilles, Tinne; Remmen, Roy
This study describes the characteristics of extramural and transmural telemonitoring projects on chronic heart failure in Belgium. It describes to what extent these telemonitoring projects coincide with the Chronic Care Model of Wagner.Background: The Chronic Care Model describes essential components for high-quality health care. Telemonitoring can be used to optimise home care for chronic heart failure. It provides a potential prospective to change the current care organisation.Methods: This...
Chung, Han-Oh; Hanvey, Louise; Mbuagbaw, Lawrence; You, John J.
Background Patients with serious illness, and their families, state that better communication and decision-making with healthcare providers is a high priority to improve the quality of end-of-life care. Numerous communication tools to assist patients, family members, and clinicians in end-of-life decision-making have been published, but their effectiveness remains unclear. Objectives To determine, amongst adults in ambulatory care settings, the effect of structured communication tools for end-of-life decision-making on completion of advance care planning. Methods We searched for relevant randomized controlled trials (RCTs) or non-randomized intervention studies in MEDLINE, EMBASE, CINAHL, ERIC, and the Cochrane Database of Randomized Controlled Trials from database inception until July 2014. Two reviewers independently screened articles for eligibility, extracted data, and assessed risk of bias. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence for each of the primary and secondary outcomes. Results Sixty-seven studies, including 46 RCTs, were found. The majority evaluated communication tools in older patients (age >50) with no specific medical condition, but many specifically evaluated populations with cancer, lung, heart, neurologic, or renal disease. Most studies compared the use of communication tools against usual care, but several compared the tools to less-intensive advance care planning tools. The use of structured communication tools increased: the frequency of advance care planning discussions/discussions about advance directives (RR 2.31, 95% CI 1.25–4.26, p = 0.007, low quality evidence) and the completion of advance directives (ADs) (RR 1.92, 95% CI 1.43–2.59, p<0.001, low quality evidence); concordance between AD preferences and subsequent medical orders for use or non-use of life supporting treatment (RR 1.19, 95% CI 1.01–1.39, p = 0.028, very low quality evidence, 1
Stanos, Steven; Brodsky, Marina; Argoff, Charles; Clauw, Daniel J; D'Arcy, Yvonne; Donevan, Sean; Gebke, Kevin B; Jensen, Mark P; Lewis Clark, Evelyn; McCarberg, Bill; Park, Peter W; Turk, Dennis C; Watt, Stephen
Chronic pain substantially impacts patient function and quality of life and is a burden to society at large in terms of increased health care utilization and loss of productivity. As a result, there is an increasing recognition of chronic pain as a public health crisis. However, there remains wide variability in clinical practices related to the prevention, assessment, and treatment of chronic pain. Certain fundamental aspects of chronic pain are often neglected including the contribution of the psychological, social, and contextual factors associated with chronic pain. Also commonly overlooked is the importance of understanding the likely neurobiological mechanism(s) of the presenting pain and how they can guide treatment selection. Finally, physicians may not recognize the value of using electronic medical records to systematically capture data on pain and its impact on mood, function, and sleep. Such data can be used to monitor onset and maintenance of treatments effects at the patient level and evaluate costs at the systems level. In this review we explain how these factors play a critical role in the development of a coordinated, evidence-based treatment approach tailored to meet specific needs of the patient. We also discuss some practical approaches and techniques that can be implemented by clinicians in order to enhance the assessment and management of individuals with chronic pain in primary care settings. PMID:27166559
Milani, Richard V; Bober, Robert M; Lavie, Carl J
Chronic disease represents the epidemic of our time, present in half the adult population and responsible for 86% of United States (US) healthcare costs and 70% of deaths. The major chronic diseases are primarily due to health risk behaviors that are widely communicable across populations. As a nation, the US has performed poorly in managing chronic disease, in large part because of a failed delivery model of care. New opportunities exist as a result of recent advances in home-based wireless devices, apps and wearables, enabling health delivery systems to monitor disease metrics in near real time. These technologies provide a framework for patient engagement and a new model of care delivery utilizing integrated practice units, both of which are needed to navigate the healthcare needs of the 21st century. PMID:26772623
Full Text Available Abstract Background Participation in daily physical activity (PA post-stroke has not previously been investigated as a possible explanatory variable of health-related quality of life (HRQL. The aims were 1 to determine the contribution of daily PA to the HRQL of individuals with chronic stroke and 2 to assess the relationship between the functional ability of these individuals to the amount of daily PA. Methods The amount of daily PA of forty adults with chronic stroke (mean age 66.5 ± 9.6 years was monitored using two measures. Accelerometers (Actical were worn on the hip for three consecutive days in conjunction with a self-report questionnaire [the PA Scale for Individuals with Physical Disabilities (PASIPD]. The daily physical activity was measured as the mean total accelerometer activity counts/day and the PASIPD scores as the metabolic equivalent (MET hr/day. HRQL was assessed by the Physical and Mental composite scores of the Medical Outcomes Study Short-Form 36 (SF-36 in addition to the functional ability of the participants. Correlation and regression analyses were performed. Results After controlling for the severity of the motor impairment, the amount of daily PA, as assessed by the PASIPD and accelerometers, was found to independently contribute to 10-12% of the variance of the Physical Composite Score of the SF-36. No significant relationship was found between PA and the Mental Composite Score of the SF-36.The functional ability of the participants was found to be correlated to the amount of daily PA (r = 0.33 - 0.67, p Conclusion The results suggest that daily PA is associated with better HRQL (as assessed by the Physical composite score of the SF-36 for people living with stroke. Daily PA should be encouraged to potentially increase HRQL. Accelerometers in conjunction with a self-report questionnaire may provide important measures of PA which can be monitored and modified, and potentially influence HRQL.
Full Text Available Abstract Background Indigenous Australians experience disproportionately high prevalence of, and morbidity and mortality from chronic illness such as diabetes, renal disease and cardiovascular disease. Improving the understanding of how Indigenous primary care systems are organised to deliver chronic illness care will inform efforts to improve the quality of care for Indigenous people. Methods This cross-sectional study was conducted in 12 Indigenous communities in Australia's Northern Territory. Using the Chronic Care Model as a framework, we carried out a mail-out survey to collect information on material, financial and human resources relating to chronic illness care in participating health centres. Follow up face-to-face interviews with health centre staff were conducted to identify successes and difficulties in the systems in relation to providing chronic illness care to community members. Results Participating health centres had distinct areas of strength and weakness in each component of systems: 1 organisational influence – strengthened by inclusion of chronic illness goals in business plans, appointment of designated chronic disease coordinators and introduction of external clinical audits, but weakened by lack of training in disease prevention and health promotion and limited access to Medicare funding; 2 community linkages – facilitated by working together with community organisations (e.g. local stores and running community-based programs (e.g. "health week", but detracted by a shortage of staff especially of Aboriginal health workers working in the community; 3 self management – promoted through patient education and goal setting with clients, but impeded by limited focus on family and community-based activities due to understaffing; 4 decision support – facilitated by distribution of clinical guidelines and their integration with daily care, but limited by inadequate access to and support from specialists; 5 delivery system
O. A. Shtegman
Full Text Available Aim. To evaluate primary care efficacy in patients with chronic heart failure (CHF.Material and methods. Outpatients (n=139 with CHF and 35 primary care physicians were included into the study. The evaluation of drug therapy and patient awareness of the principles of non-drug CHF treatment were performed. An anonymous survey among doctors in terms of current CHF guidelines knowledge, patient information provided by physicians, and doctors’ burnout status was also carried out.Results. Only 39% and 10% of CHF outpatients received target doses of ACE inhibitors/sartans and beta-blockers, respectively. Majority of CHF outpatients and their doctors need in additional education/training. 56% of primary care physicians demonstrated an emotional burnout.Conclusion. Author considers it essential to distribute short pocket-guidelines on CHF management among primary care physicians, and to reduce the load on primary care physicians with simultaneous strengthening of their performance control.
A.L. van Staa (AnneLoes); S. Jedeloo (Susan); H.A. van der Stege (Heleen)
textabstractBackground: As important users of health care, adolescents with chronic conditions deserve to be consulted about their experiences and expectations. This study aimed to explore chronically ill adolescents' preferences regarding providers' qualities, and outpatient and inpatient care. Fur
Atun, Rifat; Gurol–Urganci, Ipek; Hone, Thomas; Pell, Lisa; Stokes, Jonathan; Habicht, Triin; Lukka, Kaija; Raaper, Elin; Habicht, Jarno
Background Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system. Methods Using routinely collected health billing records for 2005–2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co–morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply–side variables, and PHC use. Findings Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow–up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services. Interpretation Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions. PMID:27175280
Radványi, Ildikó; Nagy, Lajos; Balogh, Sándor; Csikós, Ágnes
Malignant and other chronic diseases cause the death of 2.5 million people in Europe annually. It is anticipated that this number will grow due to the aging of the European population. The death of a significant proportion of patients having progressive chronic disease is preceded by an extended end of life stadium. In this stage the patients have severe symptoms and pain that necessitate their symptomatic treatment and palliative care. The assessment of the life expectancy of patients, estimation of the prognosis of their illness and, therefore, selection of patients with a need of intensified palliative care often pose difficulties. This paper provides a summary on the basic elements of "good palliative care". It introduces the most frequent models for the procession of chronic diseases and those indicators that help practicing doctors to recognise easier patients with a need of intensified palliative care, and as a result provides more adequate medical attendance that is better suited to the specific needs of the patients. PMID:26551310
Full Text Available Abstract Chronic obstructive pulmonary disease (COPD is a major cause of disability, morbidity and mortality in old age. Patients with advanced stage COPD are most likely to be admitted three to four times per year with acute exacerbations of COPD (AECOPD which are costly to manage. The adverse events of AECOPD are associated with poor quality of life, severe physical disability, loneliness, and depression and anxiety symptoms. Currently there is a lack of palliative care provision for patients with advanced stage COPD compared with cancer patients despite having poor prognosis, intolerable dyspnoea, lower levels of self efficacy, greater disability, poor quality of life and higher levels of anxiety and depression. These symptoms affect patients' quality of life and can be a source of concern for family and carers as most patients are likely to be housebound and may be in need of continuous support and care. Evidence of palliative care provision for cancer patients indicate that it improves quality of life and reduces health care costs. The reasons why COPD patients do not receive palliative care are complex. This partly may relate to prognostic accuracy of patients' survival which poses a challenge for healthcare professionals, including general practitioners for patients with advanced stage COPD, as they are less likely to engage in end-of-life care planning in contrast with terminal disease like cancer. Furthermore there is a lack of resources which constraints for the wider availability of the palliative care programmes in the health care system. Potential barriers may include unwillingness of patients to discuss advance care planning and end-of-life care with their general practitioners, lack of time, increased workload, and fear of uncertainty of the information to provide about the prognosis of the disease and also lack of appropriate tools to guide general practitioners when to refer patients for palliative care. COPD is a chronic
Noël Polly H; Jordan Michelle; McDaniel Reuben R; Lanham Holly; Palmer Ray; Leykum Luci K; Parchman Michael
Abstract Background Efforts to improve the care of patients with chronic disease in primary care settings have been mixed. Application of a complex adaptive systems framework suggests that this may be because implementation efforts often focus on education or decision support of individual providers, and not on the dynamic system as a whole. We believe that learning among clinic group members is a particularly important attribute of a primary care clinic that has not yet been well-studied in ...
Thompson, Lindsay A; Meinert, Elizabeth; Baker, Kimberly; Knapp, Caprice
Pain is common as a presenting complaint to outpatient and emergency departments for children, yet pain management represents one of the children's largest unmet needs. A child may present with acute pain for an intermittent issue or may have acute or chronic pain in the setting of chronic illness. The mainstay of treatment for pain uses a stepwise approach for pain management, such as set up by the World Health Organization. For children with life-limiting illnesses, the Institute of Medicine guidelines recommends referral upon diagnosis for palliative care, meaning that the child receives comprehensive services that include pain control in coordination with curative therapies; yet barriers remain. From the provider perspective, pain can be better addressed through a careful assessment of one's own knowledge, skills, and attitudes. The key components of pain management in children are multimodal, regardless of the cause of the pain. PMID:23329083
Bharel, Monica; Jain, Sharad; Hollander, Harry
It is challenging to create an educational and satisfying experience in the outpatient setting. We developed a 3-year ambulatory curriculum that addresses the special needs of our categorical medicine residents with distinct learning objectives for each year of training and clinical experiences and didactic sessions to meet these goals. All PGY1 residents spend 1 month on a general medicine ambulatory care rotation. PGY2 residents spend 3 months on an ambulatory block focusing on 8 core medic...
Taft, Casey; Schwartz, Sonia; Liebschutz, Jane M.
This study examined the prevalence and correlates of partner aggression perpetration in 597 primary care chronic pain patients. Approximately 30% of participants reported perpetrating low-level aggression, 12% reported injuring their partner, and 5% reported engaging in sexual coercion. Women reported more low-level aggression perpetration than men, and men reported more engagement in sexual coercion than women. Substance use disorders (SUD) were associated with all outcomes, and both aggress...
Rolando Bonal Ruiz
Full Text Available Background: the fact that chronic diseases replace traditional causes of morbidity and mortality in a country, or are on a par with major common health problems, demands the development of new strategies to address them. Objective: to explore attitudes of doctors and nurses from the Rolando López Peña Polyclinic toward the Chronic Care Model. Methods: a quantitative and qualitative cross-sectional study was conducted including the 22 family physicians and 26 nurses who provide care to patients with chronic diseases and were at the polyclinic at the time of the study. All were administered a 5 point Likert scale and a focus group interview, which was taped, transcribed and analyzed. Results: the attitudinal results correspond with the actions assessed in each component of the model, being the most common barriers: the lack of awareness and training on the new approaches to care of these patients, work overload created by other programs such as the maternal-child and vector control programs, uncertainties on the effectiveness of patient education and ignorance of the practice guidelines. Conclusions: favorable attitudes toward the introduction of the model to the practice of the family physician and nurse predominated as long as organizational changes are made and the suggestions of these service providers are put into practice with the support of the decision makers of the health sector.
Martin Carmel M
Full Text Available Abstract Background Chronic disease is a major global challenge. However, chronic illness and its care, when intruding into everyday life, has received less attention in Asia Pacific countries, including Australia, who are in the process of transitioning to chronic disease orientated health systems. Aim The study aims to examine experiences of chronic illness before and after the introduction of Australian Medicare incentives for longer consultations and structured health assessments in general practice. Methods Self-help groups around the conditions of diabetes, epilepsy, asthma and cancer identified key informants to participate in 4 disease specific focus groups. Audio taped transcripts of the focus groups were coded using grounded theory methodology. Key themes and lesser themes identified using a process of saturation until the study questions on needs and experiences of care were addressed. Thematic comparisons were made across the 2002/3 and 1992/3 focus groups. Findings At times of chronic illness, there was need to find and then ensure access to 'the right GP'. The 'right GP or specialist' committed to an in-depth relationship of trust, personal rapport and understanding together with clinical and therapeutic competence. The 'right GP', the main specialist, the community nurse and the pharmacist were key providers, whose success depended on interprofessional communication. The need to trust and rely on care providers was balanced by the need for self-efficacy 'to be in control of disease and treatment' and 'to be your own case manager'. Changes in Medicare appeared to have little penetration into everyday perceptions of chronic illness burden or time and quality of GP care. Inequity of health system support for different disease groupings emerged. Diabetes, asthma and certain cancers, like breast cancer, had greater support, despite common experiences of disease burden, and a need for research and support programs. Conclusion Core
Novinscak, Tomislav; Filipović, Marinko; Kristofić, Jelena; Toplek, Goran
Although not fully understood, close relationship between health and education ensures unambiguous health and quality of life advantages to educated individuals. Education ensures different thinking and decision making processes and man is enabled to receive information from the external world. Even though the process of education and learning still relies on banking principles and coping of common knowledge, modern and technological society drives the system as well as education opportunities towards the new learning sources. In the developed world, the impact of chronic wounds on health systems is fairly perceived, as well as chronic wound treatment and education. Our health system still neglects the significant impact of chronic wounds on social and economic, individual and community well-being. Recognizing the importance of chronic wounds and implementation of a developed educational system gives us the potential for improving care for chronic wounds, and thus to substantially improve the quality of life of patients. Furthermore, consequent reduction of unnecessary health costs could reallocate substantial resources to other points of interest. PMID:25326984
Hroscikoski, Mary C.; Solberg, Leif I.; Sperl-Hillen, JoAnn M.; Harper, Peter G.; McGrail, Michael P.; Crabtree, Benjamin F.
PURPOSE The Chronic Care Model (CCM) provides a conceptual framework for transforming health care for patients with chronic conditions; however, little is known about how to best design and implement its specifics. One large health care organization that tried to implement the CCM in primary care provided an opportunity to study these issues.
Slomka, Jacquelyn; Prince-Paul, Maryjo; Webel, Allison; Daly, Barbara J
People living with HIV (PLWH) who survive to older adulthood risk developing multiple chronic medical conditions. Health policymakers recognize the role of early palliative care and advance care planning in improving health quality for at-risk populations, but misperceptions about palliative care, hospice, and advance care planning are common. Before testing a program of early palliative care for PLWH and other chronic conditions, we conducted focus groups to elicit perceptions of palliative care, hospice, and advance care planning in our target population. Overall, participants were unfamiliar with the term palliative care, confused concepts of palliative care and hospice, and/or associated hospice care with dying. Participants misunderstood advance care planning, but valued communication about health care preferences. Accepting palliative care was contingent on distinguishing it from hospice and historical memories of HIV and dying. Provision of high-quality, comprehensive care will require changing public perceptions and individuals' views in this high-risk population. PMID:27053406
Shah, Shaival S.; Lutfiyya, May Nawal; McCullough, Joel Emery; Henley, Eric; Zeitz, Howard Jerome; Lipsky, Martin S.
Patient education in asthma management is important; however, there is little known about the characteristics of patients receiving asthma education or how often primary care physicians provide it. The objective of the study was to identify the characteristics of patients receiving asthma education. It was a cross-sectional study using 2001…
Full Text Available Objetivo. Analizar los resultados de la Encuesta Nacional de Salud II (ENSA-II, en lo relativo a los costos del proceso de búsqueda y obtención de la atención médica ambulatoria en diferentes instituciones del sector público y privado. Material y métodos. La informacion se obtuvo a partir de los indicadores de costos de la atención médica que notificó la población de estudio de la ENSA-II. Los costos para el bolsillo del consumidor fueron la variable dependiente, y las independientes, la condición de aseguramiento y el ingreso económico. La significancia de los niveles de variación se identificó aplicando la prueba de Duncan. Resultados. Los costos en todo el país, en dólares estadunidenses, fueron: transporte, $ 2.20; consulta general, $ 7.90; medicamentos, $ 9.60, y estudios de diagnóstico, $13.6. El costo promedio total de la atención ambulatoria fue de $ 22.70. Los hallazgos empíricos permiten sugerir una nueva propuesta de análisis de los costos en salud, tanto directos como indirectos, en que incurren los consumidores de servicios de salud; dichos costos representan una carga importante en relación con el ingreso familiar, situación que se agudiza en el caso de la población no asegurada. Conclusiones. La incorporación de la perspectiva económica en el análisis de los problemas de los sistemas de salud, no debe limitarse a los costos de producción de servicios en que incurren los proveedores, sobre todo si lo que se busca es resolver los problemas de equidad y accesibilidad que actualmente caracterizan a la oferta de servicios médicos en México.Objective. To analyze the results of the National Health Survey (ENSA-II as to the costs generated by the search and obtainment of ambulatory medical attention in various intitutions of the private and public health sector. Material and methods. Information was raised from the health care cost indicators reported by the study population of the ENSA-II. The dependent
Laditka Sarah B
Full Text Available Abstract Background Federally qualified community health centers (CHCs and rural health clinics (RHCs are intended to provide access to care for vulnerable populations. While some research has explored the effects of CHCs on population health, little information exists regarding RHC effects. We sought to clarify the contribution that CHCs and RHCs may make to the accessibility of primary health care, as measured by county-level rates of hospitalization for ambulatory care sensitive (ACS conditions. Methods We conducted an ecologic analysis of the relationship between facility presence and county-level hospitalization rates, using 2002 discharge data from eight states within the US (579 counties. Counties were categorized by facility availability: CHC(s only, RHC(s only, both (CHC and RHC, and neither. US Agency for Healthcare Research and Quality definitions were used to identify ACS diagnoses. Discharge rates were based on the individual's county of residence and were obtained by dividing ACS hospitalizations by the relevant county population. We calculated ACS rates separately for children, working age adults, and older individuals, and for uninsured children and working age adults. To ensure stable rates, we excluded counties having fewer than 1,000 residents in the child or working age adult categories, or 500 residents among those 65 and older. Multivariate Poisson analysis was used to calculate adjusted rate ratios. Results Among working age adults, rate ratio (RR comparing ACS hospitalization rates for CHC-only counties to those of counties with neither facility was 0.86 (95% Confidence Interval, CI, 0.78–0.95. Among older adults, the rate ratio for CHC-only counties compared to counties with neither facility was 0.84 (CI 0.81–0.87; for counties with both CHC and RHC present, the RR was 0.88 (CI 0.84–0.92. No CHC/RHC effects were found for children. No effects were found on estimated hospitalization rates among uninsured populations
S. J. Showande et al.
This study assessed the level of compliance using three different methods: pill count, self report and peak expiratory flow rate, in asthmatic patients attending a secondary health care facility. Self report (using a pre-tested structured questionnaire), peak expiratory flow rate and pill count were used to assess patient’s compliance and identify the factors which may be responsible for non compliance. Measurement of peak expiratory flow rate and the pill count were done at two different occ...
Chamberlain, Theresa Nowak; Ross-Reynolds, Jane
Interviews with 22 mothers of children with ambulatory disability and 33 nondisabled siblings showed no differences in sibling's child care responsibilities, general home responsibilities, or independence related to severity of the ambulatory disability. A difference in the amount of social activity, reported by mothers, was not confirmed by…
Neither private nor state run health care systems are perfect. Although there is increasing evidence that Health Maintenance Organizations (HMOs) provide comparable care at lower cost, HMOs tend to select healthy patients. The dual health care system in Hong Kong spends about 3.9 per cent of GDP, with health indices among the best in the world. Hong Kong still faces the problem of escalating health care expenditure. One should take advantage of the dual health care system to evolve a new paradigm for a primary-led seamless health care service. The Diabetes Centre of a university teaching hospital together with the University of Community and Family Medicine has started a structured shared care programme in diabetes mellitus, involving general practitioners in both the private and public sectors integrating the primary and secondary care, and the private and public sectors. This programme starts to develop an infrastructure for providing quality care at an affordable cost for a large pool of patients with chronic disease. Unlike other "managed care schemes", this one is not run by profit-oriented companies, but by health professionals with an interest in providing best possible care at an affordable cost. The "disease management" approach needs a care delivery system without traditional boundaries; and a continuous improvement process which develops and refines the knowledge base, guidelines and delivery system. PMID:10351265
Full Text Available Hitomi Sano,1 Sachio Kouraba,2 Rei Ogawa11Department of Plastic, Reconstructive, and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan; 2Sapporo Wound Care and Anti-Aging Laboratory, Sapporo, JapanAbstract: Chronic leg ulcers are a significant health care concern. Although deep wounds are usually treated by flap transfers, the operation is invasive and associates with serious complications. Skin grafts may be a less invasive means of covering wounds. However, skin grafts cannot survive on deep defects unless high-quality granulation tissue can first be generated in the defects. Technologies that generate high-quality granulation tissue are needed. One possibility is to use wound care matrices, which are bioengineered skin and soft tissue substitutes. Because they all support the healing process by providing a premade extracellular matrix material, these matrices can be termed “extracellular matrix replacement therapies”. The matrix promotes wound healing by acting as a scaffold for regeneration, attracting host cytokines to the wound, stimulating wound epithelialization and angiogenesis, and providing the wound bed with bioactive components. This therapy has lasting benefits as it not only helps large skin defects to be closed with thin skin grafts or patch grafts but also restores cosmetic appearance and proper function. In particular, since it acts as a layer that slides over the subcutaneous fascia, it provides skin elasticity, tear resistance, and texture. Several therapies and products employing wound care matrices for wound management have been developed recently. Some of these can be applied in combination with negative pressure wound therapy or beneficial materials that promote wound healing and can be incorporated into the matrix. To date, the clinical studies on these approaches suggest that wound care matrices promote spontaneous wound healing or can be used to facilitate skin grafting, thereby avoiding the need to use
Full Text Available Ghaya Jouini,1–3 Manon Choinière,3,4 Elisabeth Martin,2,3 Sylvie Perreault,1,5 Djamal Berbiche,2,3 David Lussier,6–8 Eveline Hudon,2,3,9 Lyne Lalonde1–3,101Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; 2Équipe de recherche en soins de première ligne, Centre de santé et de services sociaux de Laval, Laval, Quebec, Canada; 3Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM, Montreal, Quebec, Canada; 4Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; 5Sanofi-Aventis Endowment Research Chair in Optimal Drug Use, Université de Montréal, Montreal, Quebec, Canada; 6Institut universitaire de gériatrie de Montréal, Montreal, Quebec, Canada; 7Division of Geriatric Medicine and Alan-Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada; 8Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; 9Department of Family Medicine and Emergency, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; 10Sanofi-Aventis Endowment Research Chair in Ambulatory Pharmaceutical Care, Université de Montréal and Centre de santé et de services sociaux de Laval, Quebec, CanadaPurpose: Describe the pharmacotherapeutic management of primary-care patients with chronic noncancer pain, assess their satisfaction with pain treatment, and identify the determinants of their satisfaction.Methods: A cohort study was conducted in Quebec (Canada. Patients reporting chronic noncancer pain with an average pain intensity of at least 4 on a 0–10 scale (10= worst possible pain and having an active analgesic prescription from a primary-care physician were recruited. They completed a telephone interview and a self-administered questionnaire to document their pain, emotional well-being, satisfaction with treatment, and barriers/beliefs/attitudes about pain and its treatment. Information
Full Text Available Background: An integrated audit tool was developed for five chronic diseases, namely diabetes, hypertension, asthma, chronic obstructive pulmonary disease and epilepsy. Annual audits have been done in the Western Cape Metro district since 2009. The year 2012 was the first year that all six districts in South Africa’s Western Cape Province participated in the audit process.Aim: To determine whether clinical audits improve chronic disease care in health districts over time.Setting: Western Cape Province, South Africa.Methods: Internal audits were conducted of primary healthcare facility processes and equipment availability as well as a folder review of 10 folders per chronic condition per facility. Random systematic sampling was used to select the 10 folders for the folder review. Combined data for all facilities gave a provincial overview and allowed for comparison between districts. Analysis was done comparing districts that have been participating in the audit process from 2009 to 2010 (‘2012 old’ to districts that started auditing recently (‘2012 new’.Results: The number of facilities audited has steadily increased from 29 in 2009 to 129 in 2012. Improvements between different years have been modest, and the overall provincial average seemed worse in 2012 compared to 2011. However, there was an improvement in the ‘2012 old’ districts compared to the ‘2012 new’ districts for both the facility audit and the folder review, including for eight clinical indicators, with ‘2012 new’ districts being less likely to record clinical processes (OR 0.25, 95% CI 0.21–0.31.Conclusion: These findings are an indication of the value of audits to improve care processes over the long term. It is hoped that this improvement will lead to improved patient outcomes.
Powers, Jennifer G; Higham, Catherine; Broussard, Karen; Phillips, Tania J
In the United States, chronic ulcers--including decubitus, vascular, inflammatory, and rheumatologic subtypes--affect >6 million people, with increasing numbers anticipated in our growing elderly and diabetic populations. These wounds cause significant morbidity and mortality and lead to significant medical costs. Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing. In this article, we discuss recent advances in wound care technology and current management guidelines for the treatment of wounds and ulcers. PMID:26979353
Katerndahl, David; Calmbach, Walter L.; Becho, Johanna
Objective: To determine whether current depression was associated with poorer quality of care and poorer patient adherence to treatment regimens and whether current depression was associated with patient diabetes outcomes independent of its relationships to quality of care and patient adherence among patients with diabetes.
Gress, S.; Baan, C.A.; Calnan, M.; Dedeu, T.; Groenewegen, P.P.; Howson, H.
Healthcare systems in Europe struggle with inadequate co-ordination of care for people with chronic conditions. Moreover, there is a considerable evidence gap in the treatment of chronic conditions, lack of self-management, variation in quality of care, lack of preventive care, increasing costs for
Bellato, Roseney; Araújo, Laura Filomena Santos de; Dolina, Janderléia Valéria; Musquim, Cleciene Dos Anjos; Corrêa, Geovana Hagata de Lima Souza Thaines
An essay that aims to reflect on the family experience of care in chronic situation, increasing the understanding of the family as the primary caregiver. It is based on comprehensive approach in studies conducted in three matrix searches from family care experiences. We have taken three axes to organize our reflections: a) conformation of family care in chronic situation, highlighting the multiple costs incurred to the family, which can exhaust the potential of care and establish or increase its vulnerability if it is not backed by networks support and sustenance; b) family rearrangements for the care, giving visibility to care cores in which many loved family members share the care, dynamic, plural and changeable way; c) self care modeling family care, pointing to the range of possibilities of the person taking care of diseased conditions supported by people close to them. We learn that the family takes care of itself in everyday life and in the illness experience, creating networks that can provide you support and sustenance. Thus, professionals in health practices should shape up in a longitudinal and very personal way, by reference to the family care, supporting him in what is his own. Ensaio que tem por objetivo refletir sobre a experiência familiar de cuidado na situação crônica, ampliando a compreensão da família como cuidadora primária. Embasa-se em estudos de abordagem compreensiva realizados em três pesquisas matriciais que abordaram experiências familiares de cuidado. Tomamos três eixos para organizar nossas reflexões: a) conformação do cuidado familiar na situação crônica, destacando os múltiplos custos gerados à família, que podem exaurir seus potenciais de cuidado, instaurando ou ampliando sua vulnerabilidade se não for amparada por redes de apoio e sustentação; b) rearranjos familiares para o cuidado, dando visibilidade aos núcleos de cuidado compartilhados pelos diversos entes familiares, de modo dinâmico, plural e mut
Full Text Available Christopher Okunseri,1 Elaye Okunseri,1 Melissa Christine Fischer,1 Saba Noori Sadeghi,1 Qun Xiang,2 Aniko Szabo21Department of Clinical Services, School of Dentistry, Marquette University, Milwaukee, WI, USA; 2Division of Biostatistics, Institute of Health and Society, Medical College of Wisconsin, Milwaukee, WI, USAObjective: To determine whether the rates of nontraumatic dental condition (NTDC-related emergency department (ED visits are higher during the typical working hours of dental offices and lower during night hours, as well as the associated factors.Methods: We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997 through 2007 using multivariate binary and polytomous logistic regression adjusted for survey design to determine the effect of predictors on specified outcome variables.Results: Overall, 4,726 observations representing 16.4 million NTDC-related ED visits were identified. Significant differences in rates of NTDC-related ED visits were observed with 40%–50% higher rates during non-working hours and 20% higher rates on weekends than the overall average rate of 170 visits per hour. Compared with 19–33 year olds, subjects <18 years old had significantly higher relative rates of NTDC-related ED visits during nonworking hours [relative rate ratio (RRR = 1.6 to 1.8], whereas those aged 73 and older had lower relative rates during nonworking hours (RRR = 0.4; overall P = 0.0005. Compared with those having private insurance, Medicaid and self-pay patients had significantly lower relative rates of NTDC visits during nonworking and night hours (RRR = 0.6 to 0.7, overall P < 0.0003. Patients with a dental reason for visit were overrepresented during the night hours (RRR = 1.3; overall P = 0.04.Conclusion: NTDC-related visits to ED occurred at a higher rate during non-working hours and on weekends and were significantly associated with age, patient-stated reason for visit and payer type.Keywords: dental
Full Text Available Abstract Background Care for people with dementia and their informal caregivers is a challenging aim in healthcare. There is an urgent need for cost-effective support programs that prevent informal caregivers of people with dementia from becoming overburdened, which might result in a delay or decrease of patient institutionalization. For this reason, we have developed the Systematic Care Program for Dementia (SCPD. The SCPD consists of an assessment of caregiver's sense of competence and suggestions on how to deal with competence deficiencies. The efficiency of the SCPD will be evaluated in our study. Methods and design In our ongoing, cluster, randomized, single-blind, controlled trial, the participants in six mental health services in four regions of the Netherlands have been randomized per service. Professionals of the ambulatory mental health services (psychologists and social psychiatric nurses have been randomly allocated to either the intervention group or the control group. The study population consists of community-dwelling people with dementia and their informal caregivers (patient-caregiver dyads coming into the health service. The dyads have been clustered to the professionals. The primary outcome measure is the patient's admission to a nursing home or home for the elderly at 12 months of follow-up. This measure is the most important variable for estimating cost differences between the intervention group and the control group. The secondary outcome measure is the quality of the patient's and caregiver's lives. Discussion A novelty in the SCPD is the pro-active and systematic approach. The focus on the caregiver's sense of competence is relevant to economical healthcare, since this sense of competence is an important determinant of delay of institutionalization of people with dementia. The SCPD might be able to facilitate this with a relatively small cost investment for caregivers' support, which could result in a major decrease in
Purpose: To evaluate the impact of the proposed Ambulatory Patient Classification (APC) system on reimbursement for hospital outpatient Medicare procedures at the Massachusetts General Hospital (MGH) Department of Radiation Oncology. Methods and Materials: Treatment and cost data for the MGH Department of Radiation Oncology for the fiscal year 1997 were analyzed. This represented 66,981 technical procedures and 41 CPT-4 codes. The cost of each procedure was calculated by allocating departmental costs to the relative value units (RVUs) for each procedure according to accepted accounting principles. Net reimbursement for each CPT-4 procedure was then calculated by subtracting its cost from the allowed 1998 Boston area Medicare reimbursement or from the proposed Boston area APC reimbursement. The impact of the proposed APC reimbursement system on changes in reimbursement per procedure and on volume-adjusted changes in overall net reimbursements per procedure was determined. Results: Although the overall effect of APCs on volume-adjusted net reimbursements for Medicare patients was projected to be budget-neutral, treatment planning revenues would have decreased by 514% and treatment delivery revenues would have increased by 151%. Net reimbursements for less complicated courses of treatment would have increased while those for treatment courses requiring more complicated or more frequent treatment planning would have decreased. Net reimbursements for a typical prostate interstitial implant and a three-treatment high-dose-rate intracavitary application would have decreased by 481% and 632%, respectively. Conclusion: The financial incentives designed into the proposed APC reimbursement structure could lead to compromises in currently accepted standards of care, and may make it increasingly difficult for academic institutions to continue to fulfill their missions of research and service to their communities. The ability of many smaller, low patient volume, high Medicare
Full Text Available Abstract Background The Chronic Care Model (CCM is an evidence based, population based approach to improve care for people with chronic conditions. The Assessment of Chronic Illness Care (ACIC instrument is widely used to measure to what extent within a healthcare system the CCM is implemented. The aim of this study was to translate and culturally adapt the ACIC Instrument for the German healthcare system. Methods For translating the ACIC instrument, principles of Good Practice for the Translation and Cultural Adaptation Process by the ISPOR Task Force were followed. Focus groups were additionally conducted with general practitioners to adapt the items culturally. Results The ACIC instrument can not be used in the German healthcare system easily due to a multifaceted understanding of words, different levels of knowledge of the CCM and fundamental differences between health systems. Conclusions As following the CCM leads to benefits for patients with chronic illnesses, measuring to which extent it is implemented is of major interest. A new questionnaire using the CCM as its theoretical basis, sensitive to the healthcare systems of the host country has to be created. Knowledge transfer between countries by using an instrument from a different healthcare system can lead to a completely new questionnaire.
Steurer-Stey, C.; Frei, A; Rosemann, T
The Chronic care model in Swiss primary care The care of patients with chronic disease is one of the most urgent medical challenges of actual society. The chronic care model (CCM) is an organizational, proactive approach for chronic disease in primary care. The system creates practical, supportive, evidence-based interactions between an informed, activated patient and a proactive practice team. CCM identifies six essential elements of high-quality health care : community ; heal...
Objective To explore the effect of quality control circle (QCC) activities on patient satisfaction with ambulatory surgical care.Methods The operating room nursing staff formed a QCC,delved into problems affecting patient satisfaction with ambulatory surgical care,and formulated solutions to the problems through brainstorming.They put forward improvement schemes and put them into practice.Results Patient overall satisfaction with ambulatory surgical care increased from (6.80 ± 0.57) points before QCC activities to (7.41±0.44) points after the activities,with significant difference found in the scores (P＜0.01).Nurses' consciousness in participating nursing management,and job satisfaction were enhanced,and staff's enthusiasm,creativity,and initiative were fully exercised.Conclusion QCC activities help improve quality of ambulatory surgical care and patient satisfaction.%目的 探讨品管圈活动用于提升门诊手术患者满意度的效果.方法 由手术室一线护理人员组成品管圈小组,通过脑力激荡,讨论分析门诊手术患者满意度不高的原因,制订相应的整改措施并组织实施.结果 门诊手术患者总体满意度由活动前(6.80±0.57)分提高到活动后的(7.41±0.44)分,效果显著(P＜0.01)；护理人员参与护理管理的意识和工作满足感增强,护理人员的积极性、创造性、主动性得到充分发挥.结论 品管圈活动的开展,有利于提高门诊手术服务质量、提升门诊手术患者满意度.
Laupland Kevin B
Full Text Available Abstract Background Blood cultures are a gold standard specific test for diagnosing many infections. However, the low yield may limit their usefulness, particularly in low-risk populations. This study was conducted to assess the utility of blood cultures drawn from ambulatory outpatients. Methods Blood cultures drawn at community-based collection sites in the Calgary Health Region (population 1 million in 2001 and 2002 were included in this study. These patients were analyzed by linkages to acute care health care databases for utilization of acute care facilities within 2 weeks of blood culture draw. Results 3102 sets of cultures were drawn from 1732 ambulatory outpatients (annual rate = 89.4 per 100,000 population. Significant isolates were identified from 73 (2.4% sets of cultures from 51 patients, including Escherichia coli in 18 (35% and seven (14% each of Staphylococcus aureus and Streptococcus pneumoniae. Compared to patients with negative cultures, those with positive cultures were older (mean 49.6 vs. 40.1 years, p Conclusion Blood cultures drawn in outpatient settings are uncommonly positive, but may define patients for increased intensity of therapy. Strategies to reduce utilization without excluding patients with positive cultures need to be developed for this patient population.
Full Text Available Carl Llor1, Silvia Hernández1, Anna Ribas2, Carmen Álvarez3, Josep Maria Cots4, Carolina Bayona5, Isabel González6, Marc Miravitlles7, BRAMOX Study Group 1Primary Care Centre Jaume I, Tarragona, Spain; 2Primary Care Centre Santa Eugènia de Berga, Spain; 3Primary Care Centre Manlleu, Spain; 4Primary Care Centre La Marina, Barcelona, Spain; 5Primary Care Centre Valls, Spain; 6Primary Care Centre Maragall, Barcelona, Spain; 7Pneumology Department. Institut Clínic del Tòrax (IDIBAPS, Hospital Clínic, Barcelona, CIBER de Enfermedades Respiratorias (CIBERES, SpainBackground: Amoxycillin/clavulanate is considered first-line treatment for ambulatory exacerbations of COPD. However, narrow-spectrum antibiotics may be as useful for mild to moderate patients.Objective: To compare the clinical efficacy of amoxycillin versus amoxicyllin/clavulanate in exacerbations of COPD in primary care.Methods: A randomized, double-blind, noninferiority clinical trial was carried out in eight primary care centers in Catalonia, Spain. Spirometrically-diagnosed patients older than 40 years with COPD, without criteria of hospitalization and Anthonisen’s types I or II exacerbations were included. The main outcome was clinical cure at the end of treatment (EOT visit on day 10.Results: A total of 137 patients were enrolled in the study (68 assigned to amoxycillin and 69 to amoxycillin/clavulanate. The mean forced expiratory flow in one second was 61.6% and the mean age was 71.4 years. At EOT, 92.8% of patients in the amoxycillin/clavulanate and 90.9% in the amoxycillin group were considered clinically cured, a statistically non-significant difference. Adverse effects were observed in 11 subjects, 3 in the amoxycillin group and 8 in the amoxycillin/clavulanate group, 2 of whom required a change in treatment.Conclusions: Amoxycillin was at least as effective clinically and as safe as amoxycilin/clavulanate in the treatment of acute exacerbations of COPD in mild to
Manulik, Stanisław; Rosińczuk, Joanna; Karniej, Piotr
Introduction Service quality and customer satisfaction are very important components of competitive advantage in the health care sector. The SERVQUAL method is widely used for assessing the quality expected by patients and the quality of actually provided services. Objectives The main purpose of this study was to determine if patients from state and private health care facilities differed in terms of their qualitative priorities and assessments of received services. Materials and methods The study included a total of 412 patients: 211 treated at a state facility and 201 treated at a private facility. Each of the respondents completed a 5-domain, 22-item SERVQUAL questionnaire. The actual quality of health care services in both types of facilities proved significantly lower than expected. Results All the patients gave the highest scores to the domains constituting the core aspects of health care services. The private facility respondents had the highest expectations with regard to equipment, and the state facility ones regarding contacts with the medical personnel. Conclusion Health care quality management should be oriented toward comprehensive optimization in all domains, rather than only within the domain identified as the qualitative priority for patients of a given facility.
Koutkias, Vassilis G; Chouvarda, Ioanna; Triantafyllidis, Andreas; Malousi, Andigoni; Giaglis, Georgios D; Maglaveras, Nicos
The ongoing efforts toward continuity of care and the recent advances in information and communication technologies have led to a number of successful personal health systems for the management of chronic care. These systems are mostly focused on monitoring efficiently the patient's medical status at home. This paper aims at extending home care services delivery by introducing a novel framework for monitoring the patient's condition and safety with respect to the medication treatment administered. For this purpose, considering a body area network (BAN) with advanced sensors and a mobile base unit as the central communication hub from the one side, and the clinical environment from the other side, an architecture was developed, offering monitoring patterns definition for the detection of possible adverse drug events and the assessment of medication response, supported by mechanisms enabling bidirectional communication between the BAN and the clinical site. Particular emphasis was given on communication and information flow aspects that have been addressed by defining/adopting appropriate formal information structures as well as the service-oriented architecture paradigm. The proposed framework is illustrated via an application scenario concerning hypertension management. PMID:20007042
Full Text Available Gérard Reach Department of Endocrinology, Diabetes, and Metabolic Diseases, Avicenne Hospital AP-HP, and EA 3412, CRNH-IdF, Paris 13 University, Sorbonne Paris Cité, Bobigny, France Abstract: The application of the principle of autonomy, which is considered a cornerstone of contemporary bioethics, is sometimes in obvious contradiction with the principle of beneficence. Indeed, it may happen in chronic care that the preferences of the health care provider (HCP, who is largely focused on the prevention of long term complications of diseases, differ from those, more present oriented, preferences of the patient. The aims of this narrative review are as follows: 1 to show that the exercise of autonomy by the patient is not always possible; 2 where the latter is not possible, to examine how, in the context of the autonomy principle, someone (a HCP can decide what is good (a treatment for someone else (a patient without falling into paternalism. Actually this analysis leads to a paradox: not only is the principle of beneficence sometimes conflicting with the principle of autonomy, but physician's beneficence may enter into conflict with the mere respect of the patient; and 3 to propose a solution to this paradox by revisiting the very concepts of the autonomous person, patient education, and trust in the patient–physician relationship: this article provides an ethical definition of patient education. Keywords: preference, autonomy, person, reflexivity, empathy, sympathy, patient education, trust, respect, care
Ringbaek, Thomas; Martinez, Gerd; Lange, Peter
To study the long-term benefits of ambulatory oxygen (AO) in combination with pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) patients experiencing exertional desaturation.......To study the long-term benefits of ambulatory oxygen (AO) in combination with pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) patients experiencing exertional desaturation....
Background Adequate care for individuals living with chronic illnesses calls for a healthcare system redesign, moving from acute, disease-centered to patient-centered models. The aim of this study was to identify Belgian stakeholders’ perceptions on the strengths, weaknesses, opportunities and threats of the healthcare system for people with chronic diseases in Belgium. Methods Four focus groups were held with stakeholders from the micro and meso level, in addition to two interviews with stakeholders who could not attend the focus group sessions. Data collection and the discussion were based on the Chronic Care model. Thematic analysis of the transcripts allowed for the identification of the strengths, weaknesses, opportunities and threats of the current health care system with focus on chronic care. Results Informants stressed the overall good quality of the acute health care system and the level of reimbursement of care as an important strength of the current system. In contrast, the lack of integration of care was identified as one of the biggest weaknesses of today’s health care system, along with the unclear definitions of the roles and functions of health professionals involved in care processes. Patient education to support self-management exists for patients with diabetes and/or terminal kidney failure but not for those living with other or multiple chronic conditions. The current overall fee-for-service system is a barrier to integrated care, as are the lack of incentives for integrated care. Attending multidisciplinary meetings, for example, is underfinanced to date. Finally, clinical information systems lack interoperability, which further impedes the information flow across settings and disciplines. Conclusion Our study’s methods allowed for the identification of problematic domains in the health system for people living with chronic conditions. These findings provided useful insights surrounding perceived priorities. This methodology may inspire
Vilas Boas, Laís Macêdo
Full Text Available A gestação é um momento de mudanças significativas na vida da mulher, permeado por afetos, fantasias e expectativas em relação ao parto e ao bebê. A existência de um espaço de fala, no qual a futura mãe possa de algum modo elaborar tais conteúdos psíquicos, pode auxiliar tanto no processo de construção do lugar materno, como na preparação para o parto e para a interação com o bebê. O presente trabalho é uma proposta de reflexão a partir da experiência que se desenvolve no chamado Grupo de Palavras – espaço de fala e partilha de experiências de gestantes sobre questões relativas à gravidez, criado na sala de espera de um ambulatório – com objetivo de discutir nuances do processo psíquico envolvido na construção do ser mãe e a possibilidade de elaboração de tal processo por meio da fala, bem como os desafios do trabalho de escuta psicanalítica no contexto ambulatorial
Pinto, Juliana Maria de Sousa; Nations, Marilyn Kay
The provision of care causes stress in everyday family dynamics leading to physical, mental and emotional complications in caregivers and spouses' loss of liberty and/or overwork. Between March and November 2006, this anthropological research examined family caregiving in the context of Chronic Obstructive Pulmonary Disease (COPD). By means of ethnographic interviews, illness narratives and participant observation, the scope was to describe family reorganization and coexistence with the disease and its evolution, caregiver perceptions about patient difficulties and limitations experienced and strategies employed to tackle their illness. Six low-income family caregivers, living in poor, urban areas in the outskirts of the capital city, Fortaleza, Ceará, Brazil, participated in the study. From the Content Analysis, two categories arose: "sharing suffering" and "attitudes and behavior perceived and experienced by caregivers." In-depth narratives revealed marked affection between patients and their family caregivers. Despite poverty, structural violence, unemployment, social prejudice and low salaries endemic in the Northeast of Brazil, the caregivers find effective ways to cope with chronic illness besides creating strategies to diminish suffering caused by the illness. PMID:22267046
Tummers, Marcia; Knoop, Hans; Bleijenberg, Gijs
Objective: In this randomized noninferiority study, the effectiveness and efficiency of stepped care for chronic fatigue syndrome (CFS) was compared to care as usual. Stepped care was formed by guided self-instruction, followed by cognitive behavior therapy (CBT) if the patient desired it. Care as usual encompassed CBT after a waiting period.…
Ehrlich, Carolyn; Kendall, Elizabeth; Muenchberger, Heidi
People with complex chronic conditions frequently need to navigate their own way through and around a fragmented and siloed health care system. Care coordination is a defining principle of primary care and is frequently proposed as a solution to this problem. However, care coordination requires more time and effort than primary care physicians alone have the capacity to deliver. Although registered nurses (RNs) are skilled team members who can be included in the delivery of coordinated patient care, any model of care coordination that involves RNs needs to fit within the existing health care delivery system. In this study, which used qualitative techniques based on grounded theory and included face-to-face interviews and open coding and theoretical sampling until data saturation was achieved, and which was one component of a larger action research study, we aimed to gain an understanding of the difference between usual chronic condition care and the work of chronic condition care coordination. The researchers interviewed general practitioners and RNs from various general practice sites who were actively coordinating care. Four unique processes were found to define care coordination implementation, namely: (1) moving beyond usual practice by spanning boundaries; (2) relationship-based care; (3) agreed roles and routines among relevant parties; and (4) committing to chronic condition care coordination. The findings suggested that existing professional and organisational cultures required negotiation before care coordination could be integrated into existing contexts. The challenge, however, seems to be in acknowledging and overcoming professional practice boundaries that define existing care through reflective practice and shared resourcing. PMID:23050573
Depression is a widespread psychiatric disorder, which becomes chronic in 25-30% of cases. When psychiatric and psychological treatments are ineffective, chronic depressive patients are often assigned to long-term care which is mostly provided by mental health nurses. Due to factors strongly associated with chronicity (like dependency, demoralization and hopelessness) long-term care is a difficult undertaking both for patients and mental health nurses. Areas in which major problems occur are ...
Full Text Available Abstract Background A pilot experimentation of a telemonitoring system for chronic care patients is conducted in the Bilbao Primary Care Health Region (Basque Country, Spain. It seems important to understand the factors related to healthcare professionals’ acceptance of this new technology in order to inform its extension to the whole healthcare system. This study aims to examine the psychosocial factors related to telemonitoring acceptance among healthcare professionals and to apply a theory-based instrument. Methods A validated questionnaire, based on an extension of the Technology Acceptance Model (TAM, was distributed to a total of 605 nurses, general practitioners and paediatricians. Logistic regression analysis was performed to test the theoretical model. Adjusted odds ratios (OR and their 95% confidence intervals (CI were computed. Results A response rate of 44.3% was achieved. The original TAM model was good at predicting intention to use the telemonitoring system. However, the extended model, that included other theoretical variables, was more powerful. Perceived Usefulness, Compatibility, and Facilitators were the significant predictors of intention. A detailed analysis showed that intention to use telemonitoring was best predicted by healthcare professionals’ beliefs that they would obtain adequate training and technical support and that telemonitoring would require important changes in their practice. Conclusion The extended TAM explained a significant portion of the variance in healthcare professionals' intention to use a telemonitoring system for chronic care patients in primary care. The perception of facilitators in the organisational context is the most important variable to consider for increasing healthcare professionals’ intention to use the new technology.
Shantanu Nundy; Jonathan J. Dick; Goddu, Anna P.; Patrick Hogan; Lu, Chen-Yuan E.; Solomon, Marla C; Arnell Bussie; Chin, Marshall H; Peek, Monica E.
Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot...
Full Text Available Abstract Background Diabetes is a major challenge for the health care system and especially for the primary care provider. The Chronic Care Model represents an evidence-based framework for the care for chronically ill. An increasing number of studies showed that implementing elements of the Chronic Care Model improves patient relevant outcomes and process parameters. However, most of these findings have been performed in settings different from the Swiss health care system which is dominated by single handed practices. Methods/Design CARAT is a cluster randomized controlled trial with general practitioners as the unit of randomization (trial registration: ISRCTN05947538. The study challenges the hypothesis that implementing several elements of the Chronic Care Model via a specially trained practice nurse improves the HbA1c level of diabetes type II patients significantly after one year (primary outcome. Furthermore, we assume that the intervention increases the proportion of patients who achieve the recommended targets regarding blood pressure ( Discussion This study challenges the hypothesis that the Chronic Care Model can be easily implemented by a practice nurse focused approach. If our results will confirm this hypothesis the suggestion arises whether this approach should be implemented in other chronic diseases and multimorbid patients and how to redesign care in Switzerland.
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Full Text Available Lyne Lalonde,1–4 Manon Choinière,3,5 Élisabeth Martin,2,3 Djamal Berbiche,2,3 Sylvie Perreault,1,6 David Lussier7–91Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada; 2Équipe de recherche en soins de première ligne, Centre de santé et de services sociaux de Laval, Laval, QC, Canada; 3Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM, Montreal, QC, Canada; 4Sanofi Aventis Endowment Chair in Ambulatory Pharmaceutical Care, Université de Montréal and Centre de santé et de services sociaux de Laval, QC, Canada; 5Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; 6Sanofi Aventis Endowment Research Chair in Optimal Drug Use, Université de Montréal, Montreal, QC, Canada; 7Institut universitaire de gériatrie de Montréal, Montreal, QC, Canada; 8Division of Geriatric Medicine and Alan-Edwards Centre for Research on Pain, McGill University, Montreal, QC, Canada; 9Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, CanadaBackground: The economic burden of chronic noncancer pain (CNCP remains insufficiently documented in primary care.Purpose: To evaluate the annual direct health care costs and productivity costs associated with moderate to severe CNCP in primary care patients taking into account their pain disability.Materials and methods: Patients reporting noncancer pain for at least 6 months, at a pain intensity of 4 or more on a 0 (no pain to 10 (worst possible pain intensity scale, and at a frequency of at least 2 days a week, were recruited from community pharmacies. Patients' characteristics, health care utilization, and productivity losses (absenteeism and presenteeism were documented using administrative databases, pharmacies' renewal charts, telephone, and self-administered questionnaires. Patients were stratified by tertile of pain disability measured by the Brief Pain Inventory questionnaire
Sokolowski, Ineta; Maindal, Helle Terkildsen; Vedsted, Peter
Objective: To evaluate the level of chronic care patients must be involved. The Danish version of the 20-item Patient Assessment of Care for Chronic Conditions PACIC questionnaire consisting of 5 scales and an overall summary score measuring patient reported assessment of structured chronic care...... has not been evaluated with regard to psychometric properties. This study aims to assess data quality and internal consistency and to validate the proposed factorial structure. Materials and methods: Setting: Diabetes population receiving chronic care in Denmark. Subjects: A total of 624 patients aged...... same questionnaire is constructed and applied to different countries with diverse cultural backgrounds and health care systems. It is decisive, that translated questionnaires are validated in country they are used....
Darbishire, L; Ridsdale, L.; Seed, P. T.
BACKGROUND: Chronic fatigue syndrome (CFS) has been defined, but many more patients consult in primary care with chronic fatigue that does not meet the criteria for CFS. General practitioners (GPs) do not generally use the CFS diagnosis, and have some doubt about the validity of CFS as an illness. AIM: To describe the proportion of patients consulting their GP for fatigue that met the criteria for CFS, and to describe the social, psychological, and physical differences between patients with C...
Cramm, Jane Murray; Nieboer, Anna Petra
The aim of this study was to investigate whether care delivery in accordance with a care model is associated with co-productive relationships between professionals and COPD patients and their informal caregivers. A co-productive relationship refers to productive patient-professional interaction or shared decision making. This cross-sectional study was conducted in 2014 among 411 patients (out of 981) enrolled in the Dutch COPD care program Kennemer Lucht and 62 professionals treating them (out of 97). Kennemer Lucht COPD involved multicomponent interventions within all six dimensions of the chronic care model (organizational support, community, self-management, decision support, delivery system design, and information and communications technology) to improve the quality of care for patients with COPD. This approach was expected to improve relational coproduction of care between professionals and patients with COPD and their informal caregivers. Results show clearly that the perceived quality of chronic care delivery is related significantly to productive interaction/relational coproduction of care. The strength of the relationship between perceptions of quality of chronic care and relational coproduction among patients is strong (r=0.5; P≤0.001) and among professionals moderate (r=0.4; P≤0.001 relational coproduction with patients and informal caregivers). Furthermore, patients' perceptions of the quality of chronic care were associated with the existence of productive interaction with health care professionals (β=0.7; P≤0.001). The changing nature of chronic care is associated with coproduction of care, leading to the development of more productive relationships between primary care professionals and COPD patients and their informal caregivers. Further research is necessary to determine how best to sustain these developments. PMID:26869783
O'Donnell, Brian D
PURPOSE OF REVIEW: The purpose of this review is to present advances in the use of regional anesthetic techniques in ambulatory orthopedic surgery. New findings regarding the use of both neuraxial anesthesia and peripheral nerve block are discussed. RECENT FINDINGS: Neuraxial anesthesia: The use of short-acting local anesthetic agents such as mepivacaine, 2-chloroprocaine, and articaine permits rapid onset intrathecal anesthesia with early recovery profiles. Advantages and limitations of these agents are discussed.Peripheral nerve block: Peripheral nerve blocks in limb surgery have the potential to transform this patient cohort into a truly ambulatory, self-caring group. Recent trends and evidence regarding the benefits of regional anesthesia techniques are presented.Continuous perineural catheters permit extension of improved perioperative analgesia into the ambulatory home setting. The role and reported safety of continuous catheters are discussed. SUMMARY: In summary, shorter acting, neuraxial, local anesthetic agents, specific to the expected duration of surgery, may provide superior recovery profiles in the ambulatory setting. A trend towards more peripheral and selective nerve blocks exists. The infrapatellar block is a promising technique to provide analgesia following knee arthroscopy. Improved analgesia seen in the perioperative period can be safely and effectively extended to the postoperative period with the use of perineural catheters.
Full Text Available BACKGROUND : The etiology of malabsorption syndrome varies according to the geographical location and age of the patients. Scare data is available regarding the etiology of chronic diarrhoea in India. AIMS AND OBJECTIVES: To study etiology and epidemiological profile of chronic diarrhoea at a tert iary care center. MATERIAL AND METHODS: 100 patients of chronic diarrhoea were evaluated. RESULTS: Celiac sprue ( 54% remains the commonest cause of chronic diarrhoea followed by Tropical sprue (32%. Crohn’s disease, Intestinal tuberculosis, AIDS, Amyloid osis and Giardiasis. CONCLUSION: Celiac disease, Tropical sprue and Crohn’s disease are common causes of chronic diarrhoea
Does depression screening have an effect on the diagnosis and treatment of mood disorders in general medical settings?: an instrumental variable analysis of the national ambulatory medical care survey.
This study examined the association of depression screening with the diagnoses of mood disorders and prescription of antidepressants in 73,712 visits to nonpsychiatrist physician offices drawn from the 2005-2007 U.S. National Ambulatory Medical Care Survey. Physicians used depression screening selectively for patients whom they perceived as more likely to have a mood disorder. In bivariate probit analyses with instrumental variables, depression screening did not increase the prevalence of either mood disorder diagnoses or prescription of antidepressants. However, screening was associated with lower rates of antidepressants prescription without a diagnosis of a mood disorder. In visits in which antidepressants were prescribed, 47.4% of the screened visits compared with 16.3% of nonscreened visits had a mood disorder diagnosis. As currently practiced in medical settings, depression screening may help improve targeting and appropriate use of antidepressant medications. Wider use of depression screening may help curb the growing trend of off-label antidepressant prescriptions. PMID:21454246
Hale, Natalie; Paauw, Douglas S
Headaches represent the most common constellation of neurologic disorders and are a very common cause of morbidity, lost work time, and decreased quality of life among sufferers. In this article, the diagnostic features, workup, and treatment of common, nuanced, and difficult-to-diagnose headache conditions were addressed. The future will hold a number of changes, with respect to both the diagnosis and treatment of headache disorders. As the aging population continues to grow, primary care providers will need to become increasingly familiar with differentiating between benign primary and more serious secondary headache disorders and will need to be able to treat the headache disorders unique to the elderly. With respect to therapeutic options, the future for treatment of the various headache disorders is promising. With the rise in popularity of complementary medical practices, there is likely to be more research on the roles of acupuncture, herbal and alternative remedies, massage therapy, and mind-body techniques. Further, new research is suggesting that neurostimulation may be useful in certain chronic, intractable headache conditions. Finally, the pathophysiology of headache disorders is still poorly understood and there is great hope that better understanding of the underlying mechanics of headache might contribute to improved treatment modalities and better quality of life for patients. PMID:24758958
Cano Franco, Isaac
Tesi realitzada a l'Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) BACKGROUND The epidemics of non-communicable diseases and the need for cost-containment are triggering a profound reshaping of healthcare delivery toward adoption of the Chronic Care model, involving deployment of integrated care services (ICS) with the support of information and communication technologies (ICS-ICT). In this scenario, emerging systems medicine, with a holistic mechanism-based approa...
Kanter, Michael; Martinez, Osvaldo; Lindsay, Gail; Andrews, Kristen; Denver, Cristine
In 2007, Kaiser Permanente's (KP) Southern California Region designed and implemented a systematic in-reach program, the Proactive Office Encounter (POE), to address the growing needs of its three million patients for preventive care and management of chronic disease. The program sought staff from both primary and specialty care departments to proactively identify gaps in care and to assist physicians in closing those gaps. The POE engaged the entire health team in a proactive patient-care ex...
This paper takes up the subject of the place and role of individual psychotherapy of people diagnosed with schizophrenia in the Polish system of psychiatric care. It describes various therapeutic contexts in which such psychotherapy can take place: inpatient ward, outpatient ward, ambulatory care, community care team. It also touches upon the issue of psychotherapy in contact with a chronically ill patient who participates in rehabilitation at occupational therapy workshops or at a day care c...
Anderson, Ruth A; Bailey, Donald E; Wu, Bei; Corazzini, Kirsten; McConnell, Eleanor S; Thygeson, N Marcus; Docherty, Sharron L
We propose the Adaptive Leadership Framework for Chronic Illness as a novel framework for conceptualizing, studying, and providing care. This framework is an application of the Adaptive Leadership Framework developed by Heifetz and colleagues for business. Our framework views health care as a complex adaptive system and addresses the intersection at which people with chronic illness interface with the care system. We shift focus from symptoms to symptoms and the challenges they pose for patients/families. We describe how providers and patients/families might collaborate to create shared meaning of symptoms and challenges to coproduce appropriate approaches to care. PMID:25647829
Gristina, Giuseppe R; Orsi, Luciano; Carlucci, Annalisa; Causarano, Ignazio R; Formica, Marco; Romanò, Massimo
In Italy the birth rate decrease together with the continuous improvement of living conditions on one hand, and the health care progress on the other hand, led in recent years to an increasing number of patients with chronic mono- or multi-organ failures and in an extension of their life expectancy. However, the natural history of chronic failures has not changed and the inescapable disease's worsening at the end makes more rare remissions, increasing hospital admissions rate and length of stay. Thus, when the "end-stage" get close clinicians have to engage the patient and his relatives in an advance care planning aimed to share a decision making process regarding all future treatments and related ethical choices such as patient's best interests, rights, values, and priorities. A right approach to the chronic organ failures end-stage patients consists therefore of a careful balance between the new powers of intervention provided by the biotechnology and pharmacology (intensive care), both with the quality of remaining life supplied by physicians to these patients (proportionality and beneficence) and the effective resources rationing and allocation (distributive justice). However, uncertainty still marks the criteria used by doctors to assess prognosis of these patients in order to make decisions concerning intensive or palliative care. The integrated care pathway suggested in this position paper shared by nine Italian medical societies, has to be intended as a guide focused to identify end-stage patients and choosing for them the best care option between intensive treatments and palliative care. PMID:24553592
Objective. The study aims to determine the prevalence of undiagnosed comorbid mood disorders in patients suffering chronic musculoskeletal pain in a primary care setting and to identify sleep disturbances and other associated factors in these patients, and to compare the use of health services by chronic musculoskeletal pain patients with and without comorbid mood disorders. Design. Cross-sectional study. Subjects. A total of 1,006 patients with chronic musculoskele...
Koley, Munmun; Saha, Subhranil; Ghosh, Shubhamoy; Nag, Goutam; Kundu, Monojit; Mondal, Ramkumar; Purkait, Rajib; Patra, Supratim; Ali, Seikh Swaif
Homeopathy research has focused on chronic conditions; however, the extent to which current homeopathic care is compliant with the Chronic Care Model (CCM) has been sparsely shown. As the Bengali Patient-Assessed Chronic Illness Care (PACIC)-20 was not available, the English questionnaire was translated and evaluated in a government homeopathic hospital in West Bengal, India. The translation was done in six steps, and approved by an expert committee. Face validity was tested by 15 people for comprehension. Test/retest reliability (reproducibility) was tested on 30 patients with chronic conditions. Internal consistency was tested in 377 patients suffering from various chronic conditions. The questionnaire showed acceptable test/retest reliability [intraclass correlation coefficient (ICC) 0.57-0.75; positive to strong positive correlations; p 0.05); however, monthly household income had a significant influence (p < 0.05) on the subscales except for "delivery system or practice design." Overall, chronic illness care appeared to be quite promising and CCM-compliant. The psychometric properties of the Bengali PACIC-20 were satisfactory, rendering it a valid and reliable instrument for assessing chronic illness care among the patients attending a homeopathic hospital. PMID:26933640
Ruiz, Jorge G.; Qadri, S. Sobiya; Nader, Samir; Wang, Jia; Lawler, Timothy; Hagenlocker, Brian; Roos, Bernard A.
Clinicians managing older patients with chronic pain play an important role. This paper explores the attitudes of primary care clinicians (PCPs) toward chronic nonmalignant pain management and their experiences using a clinical decision support system. Our investigation followed a qualitative approach based on grounded theory. Twenty-one PCPs…
Jiao, Jocelyn M; So, Eric; Jebakumar, Jebakaran; George, Mary Catherine; Simpson, David M; Robinson-Papp, Jessica
Chronic pain is common in HIV, but incompletely characterized, including its underlying etiologies, its effect on healthcare utilization, and the characteristics of affected patients in the HIV primary care setting. These data are needed to design and justify appropriate clinic-based pain management services. Using a clinical data warehouse, we analyzed one year of data from 638 patients receiving standard-of-care antiretroviral therapy in a large primary care HIV clinic, located in the Harlem neighborhood of New York City. We found that 40% of patients carried one or more chronic pain diagnoses. The most common diagnoses were degenerative musculoskeletal disorders (eg, degenerative spinal disease and osteoarthritis), followed by neuropathic pain and headache disorders. Many patients (16%) had multiple chronic pain diagnoses. Women, older patients, and patients with greater burdens of medical illness, and psychiatric and substance use comorbidities were disproportionately represented among those with chronic pain diagnoses. Controlling for overall health status, HIV patients with chronic pain had greater healthcare utilization including emergency department visits and radiology procedures. In summary, our study demonstrates the high prevalence of chronic pain disorders in the primary care HIV clinic. Colocated interventions for chronic pain in this setting should not only focus on musculoskeletal pain but also account for complex multifaceted pain syndromes, and address the unique biopsychosocial features of this population. Furthermore, because chronic pain is prevalent in HIV and associated with increased healthcare utilization, developing clinic-based pain management programs could be cost-effective. PMID:26683238
Morales-Espinoza, Enma Marianela; Kostov, Belchin; Salami, Daniel Cararach; Perez, Zoe Herreras; Rosalen, Anna Pereira; Molina, Jacinto Ortiz; Paz, Luis Gonzalez-de; Momblona, Josep Miquel Sotoca; Àreu, Jaume Benavent; Brito-Zerón, Pilar; Ramos-Casals, Manuel; Sisó-Almirall, Antoni
The objective was to estimate the prevalence of chronic widespread pain (CWP) and compare the quality-of-life (QoL), cardiovascular risk factors, comorbidity, complexity, and health costs with the reference population. A multicenter case-control study was conducted at 3 primary care centers in Barcelona between January and December 2012: 3048 randomized patients were evaluated for CWP according to the American College of Rheumatology definition. Questionnaires on pain, QoL, disability, fatigue, anxiety, depression, and sleep quality were administered. Cardiovascular risk and the Charlson index were calculated. We compared the complexity of cases and controls using Clinical Risk Groups, severity and annual direct and indirect health care costs. CWP criteria were found in 168 patients (92.3% women, prevalence 5.51% [95% confidence interval: 4.75%-6.38%]). Patients with CWP had worse QoL (34.2 vs 44.1, P Costs were &OV0556;3751 per year in patients with CWP vs &OV0556;1397 in controls (P cost associated with CWP is nearly 3 times higher than that of patients without CWP, controlling for other clinical factors. These findings have implications for disease management and budgetary considerations. PMID:26645546
Holm, Jens-Christian; Gamborg, Michael; Bille, Dorthe S;
Clinically-relevant protocols for the treatment of childhood obesity are lacking. This study report results for a clinic-based structured treatment program for chronic childhood obesity.......Clinically-relevant protocols for the treatment of childhood obesity are lacking. This study report results for a clinic-based structured treatment program for chronic childhood obesity....
Tam H Ho
Full Text Available OBJECTIVE: To assess the impact of individualised, reconciled evidence-based recommendations (IRERs and multidisciplinary care in patients with chronic heart failure (CHF on clinical guideline compliance for CHF and common comorbid conditions. DESIGN AND SETTING: A retrospective hospital clinical audit conducted between 1st July 2006 and February 2011. PARTICIPANTS: A total of 255 patients with a diagnosis of CHF who attended the Multidisciplinary Ambulatory Consulting Services (MACS clinics, at the Royal Adelaide Hospital, were included. MAIN OUTCOME MEASURES: Compliance with Australian clinical guideline recommendations for CHF, atrial fibrillation, diabetes mellitus and ischaemic heart disease. RESULTS: Study participants had a median of eight medical conditions (IQR 6-10 and were on an average of 10 (±4 unique medications. Compliance with clinical guideline recommendations for pharmacological therapy for CHF, comorbid atrial fibrillation, diabetes or ischaemic heart disease was high, ranging from 86% for lipid lowering therapy to 98% anti-platelet agents. For all conditions, compliance with lifestyle recommendations was lower than pharmacological therapy, ranging from no podiatry reviews for CHF patients with comorbid diabetes to 75% for heart failure education. Concordance with many guideline recommendations was significantly associated if the patient had IRERs determined, a greater number of recommendations, more clinic visits or if patients participated in a heart failure program. CONCLUSIONS: Despite the high number of comorbid conditions and resulting complexity of the management, high compliance to clinical guideline recommendations was associated with IRER determination in older patients with CHF. Importantly these recommendations need to be communicated to the patient's general practitioner, regularly monitored and adjusted at clinic visits.
Chronic pain and its associated syndrome have become increasingly prevalent in primary care. With the increase in narcotic use and subsequent adverse events, primary care physicians often seek safer alternatives to treating this condition. Prescribing narcotics necessitates using methods to screen for high abuse risk and protect against misuse. With the understanding of how chronic pain is related to mental illnesses such as depression and posttraumatic stress disorder, mindfulness techniques and behavioral therapy can be used to help decrease the dependence on dangerous opioid medications and help patients understand, accept, and cope with their chronic pain. PMID:27262002
Petersen, Ruth; Rushing, Jill; Nelson, Sharon; Rhyne, Sharon
Today's health system transformation provides a prime opportunity to leverage the capacity of public health to reduce the burden of chronic disease and injury, improve population health, and contain health care costs. Health care settings and organizations should support public health capacity as a key investment in population health. PMID:27422946
Ferrari, Joseph R.; Jason, Leonard A.
Examined adult caregivers (N=96) caring for persons with Chronic Fatigue Syndrome (CFS) on a long-term basis. Results indicate no significant sex difference regarding caregiver stress and satisfaction. The more life satisfaction caregivers reported, the less stress and more satisfaction they experienced in caring for a person with CFS. (RJM)
Henningsen, Kim; Dyrvig, Mads; Bouzinova, Elena V;
In the present study we report the finding that the quality of maternal care, in early life, increased the susceptibility to stress exposure in adulthood, when rats were exposed to the chronic mild stress paradigm. Our results indicate that high, as opposed to low maternal care, predisposed rats ...
Wilson, Donna M.; Ross, Carolyn; Goodridge, Donna; Davis, Penny; Landreville, Alison; Roebuck, Kim
Aim: This study was undertaken to determine the care needs of Canadian seniors living at home with advanced chronic obstructive pulmonary disease (COPD). Background: COPD is a leading cause of morbidity and mortality worldwide. Although hospitalizations for illness exacerbations and end-stage care may be common, most persons with COPD live out…
This study provides evidence of a successful implementation of a not-for-profit operational model within a public setting. The federal government placed a receiver in charge of improving health care within the California Department of Corrections and Rehabilitation. To achieve the receivership's goals, a chronic care model from the not-for-profit sector was selected and implemented to improve the delivery of health care to inmates. The data suggest that operational programs developed outsi...
Full Text Available Mia Skov-Madsen, My Svensson, Jeppe Hagstrup ChristensenDepartment of Nephrology, Aarhus University Hospital, Aalborg, DenmarkIntroduction: Twenty four-hour ambulatory blood pressure monitoring is a clinically validated procedure in evaluation of blood pressure (BP. We hypothesised that the discomfort during cuff inflation would increase the heart rate (HR measured with 24-h ambulatory BP monitoring compared to a following HR measurement with a 24-h Holter monitor.Methods: The study population (n = 56 were recruited from the outpatient’s clinic at the Department of Nephrology, Aalborg Hospital, Aarhus University Hospital at Aalborg, Denmark. All the patients had chronic kidney disease (CKD. We compared HR measured with a 24-h Holter monitor with a following HR measured by a 24-h ambulatory BP monitoring.Results: We found a highly significant correlation between the HR measured with the Holter monitor and HR measured with 24-h ambulatory blood pressure monitoring (r = 0.77, p < 0.001. Using the Bland-Altman plot, the mean difference in HR was only 0.5 beat/min during 24 hours with acceptable limits of agreement for both high and low HR levels. Dividing the patients into groups according to betablocker treatment, body mass index, age, sex, angiotensin-converting enzyme inhibitor treatment, statins treatment, diuretic treatment, or calcium channel blocker treatment revealed similar results as described above.Conclusion: The results indicate that the discomfort induced by cuff inflation during 24-h ambulatory BP monitoring does not increase HR. Thus, 24-h ambulatory BP monitoring may be a reliable measurement of the BP among people with CKD.Keywords: ambulatory blood pressure monitoring, Holter monitoring, heart rate, chronic kidney disease, hypertension
Tsiachristas, Apostolos; Lionis, Christos; Yfantopoulos, John
The health, social and economic impact of chronic diseases is well documented in Europe. However, chronic diseases threaten relatively more the 'memorandum and peripheral' Eurozone countries (i.e., Greece, Spain, Portugal and Ireland), which were under heavy recession after the economic crisis in 2009. Especially in Greece, where the crisis was the most severe across Europe, the austerity measures affected mainly people with chronic diseases. As a result, the urgency to tackle the threat of chronic diseases in Greece by promoting public health and providing effective chronic care while flattening the rising health care expenditure is eminent. In many European countries, integrated care is seen as a means to achieve this. The aim of this paper was to support Greek health policy makers to develop an action plan from 2015 onwards, to integrate care by bridging local policy context and needs with knowledge and experience from other European countries. To achieve this aim, we adopted a conceptual framework developed by the World Health Organization on one hand to analyse the status of integrated care in Greece, and on the other to develop an action plan for reform. The action plan was based on an analysis of the Greek health care system regarding prerequisite conditions to integrate care, a clear understanding of its context and successful examples of integrated care from other European countries. This study showed that chronic diseases are poorly addressed in Greece and integrated care is in embryonic stage. Greek policy makers have to realise that this is the opportunity to make substantial reforms in chronic care. Failing to reform towards integrated care would lead to the significant risk of collapse of the Greek health care system with all associated negative consequences. The action plan provided in this paper could support policy makers to make the first serious step to face this challenge. The details and specifications of the action plan can only be decided by
Full Text Available The health, social and economic impact of chronic diseases is well documented in Europe. However, chronic diseases threaten relatively more the ‘memorandum and peripheral’ Eurozone countries (i.e., Greece, Spain, Portugal and Ireland, which were under heavy recession after the economic crisis in 2009. Especially in Greece, where the crisis was the most severe across Europe, the austerity measures affected mainly people with chronic diseases. As a result, the urgency to tackle the threat of chronic diseases in Greece by promoting public health and providing effective chronic care while flattening the rising health care expenditure is eminent. In many European countries, integrated care is seen as a means to achieve this.The aim of this paper was to support Greek health policy makers to develop an action plan from 2015 onwards, to integrate care by bridging local policy context and needs with knowledge and experience from other European countries. To achieve this aim, we adopted a conceptual framework developed by the World Health Organization on one hand to analyse the status of integrated care in Greece, and on the other to develop an action plan for reform. The action plan was based on an analysis of the Greek health care system regarding prerequisite conditions to integrate care, a clear understanding of its context and successful examples of integrated care from other European countries. This study showed that chronic diseases are poorly addressed in Greece and integrated care is in embryonic stage.Greek policy makers have to realise that this is the opportunity to make substantial reforms in chronic care. Failing to reform towards integrated care would lead to the significant risk of collapse of the Greek health care system with all associated negative consequences. The action plan provided in this paper could support policy makers to make the first serious step to face this challenge. The details and specifications of the action plan
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Glover, Saundra; Bellinger, Jessica D.; Bae, Sejong; Rivers, Patrick A.; Singh, Karan P.
Objective: The objective of this study is to determine racial and ethnic variations in specialty care utilization based on (a) perceived health status and (b) chronic disease status. Methods: Variations in specialty care utilization, by perceived health and chronic disease status, were examined using the Commonwealth Fund Health Care Quality…
Seidel, Dörthe; Mathes, Tim; Lefering, Rolf; Storck, Martin; Lawall, Holger; Neugebauer, Edmund A. M.
Background In August 2010, the Federal Joint Committee (G-BA) decided that negative pressure wound therapy (NPWT) would not be reimbursable in German ambulatory care. This decision was based on reports from the Institute for Quality and Efficiency in Health Care (IQWiG), which concluded that there is no convincing evidence in favor of NPWT. The aim of this diabetic foot study (DiaFu study) is to evaluate whether the clinical, safety and economic results of NPWT are superior to the results of ...
Enfermagem em cirurgia ambulatorial de um hospital escola: clientela, procedimentos e necessidades biológicas e psicossociais Enfermería en cirugía ambulatoria en hospital escuela: clientela, procedimientos y necesidades biológicas y psicosociales Nursing care in ambulatory surgery at a teaching hospital: patients, procedures and biological and psychosocial needs
Tatiane Vegette Pinto
local con o sin sedación. Como necesidades biológicas fueron identificadas: alteraciones en la tensión arterial, alteraciones electrocardiográficas, uso de medicamentos y alergias a los mismos, ayuno prolongado, náusea, vómito y dolor; como necesidades psicosociales: preocupación, miedo, ansiedad, incomodo por la espera para realizarse el procedimiento y dudas o desconocimiento respecto a los cuidados perioperatorios.This descriptive study aimed to characterize the profile of 167 subjects who were treated at the Ambulatory Surgical Center of a University Hospital in São Paulo State and procedures realized at the Ambulatory Surgical Center, as well as to identify the biological and psychosocial needs of these patients. Data were obtained through a semistructured interview and patients' files and were subject to descriptive analysis. The group was characterized by an equal number of individuals from both genders; average age was 51 years and socioeconomic levels were poor. The most common surgical and anesthetic procedures were ophthalmologic procedures and use of local anesthesia with or without sedation. The biological needs were: altered arterial pressure, electrocardiographic alterations, use of medication, allergy to medication, prolonged fasting, nausea, vomits and pain. The psychosocial needs were: worry, fear, anxiety, discomfort caused by waiting for the realization of procedures and doubts or lack of information concerning perioperative care.
Stuber, Kent Jason; Langweiler, Mark; Mior, Silvano; McCarthy, Peter William
Background The management of chronic health conditions increasingly requires an organized, coordinated, and patient-centered approach to care. The Chronic Care Model (CCM) has been adopted in primary care to improve care delivery for those with chronic health conditions. Chiropractors manage chronic health conditions; however, little is known if such care is patient-centered. The primary aim of this study is to determine to what extent chiropractic patients with chronic health conditions perc...
Full Text Available Ushma Shah, David T Wong, Jean Wong Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada Abstract: Most surgeries in North America are performed on an ambulatory basis, reducing health care costs and increasing patient comfort. Patient satisfaction is an important outcome indicator of the quality of health care services incorporated by the American Society of Anesthesiologists (ASA. Patient satisfaction is a complex concept that is influenced by multiple factors. A patient's viewpoint and knowledge plays an influential role in patient satisfaction with ambulatory surgery. Medical optimization and psychological preparation of the patient plays a pivotal role in the success of ambulatory surgery. Postoperative pain, nausea, and vomiting are the most important symptoms for the patient and can be addressed by multimodal drug regimens. Shared decision making, patient–provider relationship, communication, and continuity of care form the main pillars of patient satisfaction. Various psychometrically developed instruments are available to measure patient satisfaction, such as the Iowa Satisfaction with Anesthesia Scale and Evaluation du Vecu de I'Anesthesie Generale, but none have been developed specifically for ambulatory surgery. The ASA has made recommendations for data collection for patient satisfaction surveys and emphasized the importance of reporting the data to the Anesthesia Quality Institute. Future research is warranted to develop a validated tool to measure patient satisfaction in ambulatory surgery. Keywords: patient, satisfaction, anesthesia, outcomes, questionnaire, perspectives
Manoj Kumar Sharma; Atul Kumar; Mahalingam Venkateshan
Background: Chronic obstructive pulmonary disease is a lung disease that makes it hard to breathe and patient education is integral to the care of patients with chronic obstructive pulmonary disease (COPD), also cornerstone of self-management in chronic illness. This study was aimed to improve the knowledge of COPD patients regarding self-care management of COPD. Methods: Quasi experimental (pre-test and post-test with control group) research design was used. Sixty COPD patients were sele...
Priority Setting and Influential Factors on Acceptance of Pharmaceutical Recommendations in Collaborative Medication Reviews in an Ambulatory Care Setting – Analysis of a Cluster Randomized Controlled Trial (WestGem-Study)
Rose, Olaf; Mennemann, Hugo; John, Carina; Lautenschläger, Marcus; Mertens-Keller, Damaris; Richling, Katharina; Waltering, Isabel; Hamacher, Stefanie; Felsch, Moritz; Herich, Lena; Czarnecki, Kathrin; Schaffert, Corinna; Jaehde, Ulrich; Köberlein-Neu, Juliane
Background Medication reviews are recognized services to increase quality of therapy and reduce medication risks. The selection of eligible patients with potential to receive a major benefit is based on assumptions rather than on factual data. Acceptance of interprofessional collaboration is crucial to increase the quality of medication therapy. Objective The research question was to identify and prioritize eligible patients for a medication review and to provide evidence-based criteria for patient selection. Acceptance of the prescribing general practitioner to implement pharmaceutical recommendations was measured and factors influencing physicians’ acceptance were explored to obtain an impression on the extent of collaboration in medication review in an ambulatory care setting. Methods Based on data of a cluster-randomized controlled study (WestGem-study), the correlation between patient parameters and the individual performance in a medication review was calculated in a multiple logistic regression model. Physician’s acceptance of the suggested intervention was assessed using feedback forms. Influential factors were analyzed. Results The number of drugs in use (p = 0.001), discrepancies between prescribed and used medicines (p = 0.014), the baseline Medication Appropriateness Index score (p0.05) and a low kidney function (p>0.05) do not predetermine the outcome. Longitudinal patient care with repeated reviews showed higher interprofessional acceptance and superior patient benefit. A total of 54.9% of the recommendations in a medication review on drug therapy were accepted for implementation. Conclusions The number of drugs in use and medication reconciliation could be a first rational step in patient selection for a medication review. Most elderly, multimorbid patients with polymedication experience a similar chance of receiving a benefit from a medication review. Longitudinal patient care should be preferred over confined medication reviews. The acceptance
Popoola, Mercy Mammah
Holistic caring consists of providing care to each aspect of a patient's life through the use of therapeutic caring and complementary or alternative healing modalities. Since nursing consists of caring for the whole person and not just the disease process, consideration of a patient's physical, emotional, social, economic, spiritual, and cultural needs is necessary in dealing with any chronic health problem such as chronic wounds. In this model case studies presentation, the purpose of this article is to discuss the importance of the holistic caring approach and the use of complementary and alternative medicine or therapeutic modalities in chronic wound management. The use or role of theory in practice will also be discussed to emphasize the holistic caring praxis model used in the holistic assessment and holistic plan of care for the cases presented. This article also presents a framework that will help wound care and holistic nurses move from simply the positivist-modernist philosophy to begin to embrace the postmodernist philosophy. PMID:12784899
Hamar, Brent; Wells, Aaron; Gandy, William; Haaf, Andreas; Coberley, Carter; Pope, James E.; Rula, Elizabeth Y.
Hospital admissions are the source of significant health care expenses, although a large proportion of these admissions can be avoided through proper management of chronic disease. In the present study, we evaluate the impact of a proactive chronic care management program for members of a German insurance society who suffer from chronic disease. Specifically, we tested the impact of nurse-delivered care calls on hospital admission rates. Study participants were insured individuals with corona...
Purpose An evaluation of an Integrated Care approach with the aim of exploring the components of the service which contributed to its functioning. Theory There is growing recognition internationally that conventional approaches to the management of chronic illness are not adequately meeting the needs of people with such conditions. This concern is also shared in Ireland and a pilot programme to provide an alternative community based approach was established in Callan, Co. Kilkennny, Ireland f...
Fry-Bowers, Eileen Katherine
Objective: Child health outcomes depend on a parent's ability to read, communicate, analyze, and use health information to participate in their child's care. Low maternal health literacy (HL) may disrupt access to pediatric health care, impede informed parent decision-making, and exacerbate pediatric health disparities. This dissertation explores relationships between maternal (HL), maternal self-efficacy (SE) in communication, interpersonal interactions with health care providers (HCPs), a...
Bond, Gail E; Rechholtz, Laurie; Bosa, Christina; Impert, Celine; Barker, Sara
Problem statement Unprecedented consumption of health care resources in the USA coupled with increasing rates of chronic disease has fueled pursuit of improved models of health care delivery. The Chronic Care Model provides an organizational framework for chronic care management and practice improvement. Sea Mar, a community health care organization in Washington state, implemented the Chronic Care Model, but has not evaluated the outcomes related to provider and staff satisfaction. The speci...
Muntinga Maaike E; Hoogendijk Emiel O; van Leeuwen Karen M; van Hout Hein PJ; Twisk Jos WR; van der Horst Henriette E; Nijpels Giel; Jansen Aaltje PD
Abstract Background Care for older adults is facing a number of challenges: health problems are not consistently identified at a timely stage, older adults report a lack of autonomy in their care process, and care systems are often confronted with the need for better coordination between health care professionals. We aim to address these challenges by introducing the geriatric care model, based on the chronic care model, and to evaluate its effects on the quality of life of community-dwelling...
Vadivelu, Nalini; Kai, Alice M; Kodumudi, Vijay; Berger, Jack M
Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed. PMID:27382329
A K Rajani
Full Text Available Chronic hepatitis C is a major public health problem and its burden is expected to increase in the near future. Out of six genotypes of hepatitis C virus (HCV identified, genotype 1 is the most prevalent genotype in America and Europe. With peg-interferon alpha and ribavirin dual therapy, sustained virological response (SVR is achieved in less than half of the patients infected with HCV genotype 1. Moreover, this dual therapy also causes many intolerable adverse effects. Telaprevir is an HCV protease inhibitor approved for chronic hepatitis C genotype 1 mono-infection. It is a type of direct acting antiviral drug acting through inhibition of viral non-structural 3/4A protease. It can be safely administered in mild hepatic dysfunction. Due to inhibition of CYP3A4 and P-glycoprotein, significant drug-drug interactions are possible with telaprevir. Trials have shown significantly higher SVR rates when telaprevir is added to peg-interferon alpha and ribavirin, particularly in patients with unfavorable prognostic factors. It is approved for use in treatment-naïve and previously treated patients. Rash and anemia are the major troublesome side-effects. Next-generation protease inhibitors may overcome the drawbacks of telaprevir and another approved HCV protease inhibitor - boceprevir. Evidence from small scale studies suggests that telaprevir may be used in conditions like HIV co-infection, post-transplantation and some HCV non-1 genotype infections also. Preliminary data show higher SVR rates with triple therapy even in patients with unfavorable interleukin-28B (IL28B genotype. With development of other direct acting antivirals, it might be possible to treat chronic hepatitis C with interferon-free regimens in future. This article briefly reviews the properties of telaprevir and its status in the context of rapidly evolving aspects of management of chronic hepatitis C.
Zaner, Richard M; Bliton, Mark J
... While Spiegelberg emphasizes these "cosmic" -- perhaps more accurately, ontological -- features of birth and undeserved inequalities, it seems to us not inappropriate to suggest that what Douard terms "outrage" and Annas "instinct" go in the same direction. When impairment occurs without desert, something should be done to help. This is all the more true when, as in cases of chronic affliction that concern Douard or the case of the Siamese twins that fascinates Annas, something helpful can be done. Then, in Spiegelberg's words, what is "undeserved" demands redress. In these terms, each of these authors points to a deeply rooted sense of our common human lot. Or, in Albert Schweitzer's apt phrase, to witness such undeserved misfortune is to awaken "a moral sense that is usually dormant but that on special occasions can be brought to the surface." Chronic illnesses, we suggest -- no less than the "accidents of birth" that concern Spiegelberg -- are just such "special occasions" for awakening that "moral sense" suggested by Douard in his appeal to the "outrage" of doing nothing for, or refusing to help, the chronically ill. PMID:11642945
Talboom-Kamp, Esther Pwa; Verdijk, Noortje A; Harmans, Lara M; Numans, Mattijs E; Chavannes, Niels H
The number of individuals with chronic illness and multimorbidity is growing due to the rapid ageing of the population and the greater longevity of individuals. This causes an increasing workload in care, which results in a growing need for structural changes of the health care system. In recent years this led to a strong focus on promoting "self-management" in chronically ill patients. Research showed that patients who understand more about their disease, health, and lifestyle have better experiences and health outcomes, and often use less health care resources; the effect is even more when these patients are empowered to and responsible for managing their health and disease. In addition to the skills of patients, health care professionals need to shift to a role of teacher, partner, and professional supervisor of their patients. One way of supervising patients is by the use of electronic health (eHealth), which helps patients manage and control their disease. The application of eHealth solutions can provide chronically ill patients high-quality care, to the satisfaction of both patients and health care professionals, alongside a reduction in health care consumption and costs. PMID:26860333
Wroe, Emily B; Kalanga, Noel; Mailosi, Bright; Mwalwanda, Stanley; Kachimanga, Chiyembekezo; Nyangulu, Kondwani; Dunbar, Elizabeth; Kerr, Lila; Nazimera, Lawrence; Dullie, Luckson
This case study describes an integrated chronic care clinic that utilizes a robust HIV program as a platform for NCD screening and treatment. A unique model, the integrated chronic care clinic provides longitudinal care for patients with an array of chronic diseases including HIV and common NCDs, allowing for a single visit for all of a patient's conditions. Set in Malawi's remote Neno District, this clinic structure aims to (1) increase access to care for NCD patients, (2) maximize efficiency given the severe human resource shortages, and (3) replicate strong HIV outcomes for patients with other chronic conditions. The goal is to increase the number of health facilities in Neno capable of fully delivering Malawi's Essential Health Package, the set of cost-effective interventions endorsed by Malawi MOH to reduce burden of disease and leading causes of death. While implementation is ongoing and processes are evolving, this model of healthcare delivery has already improved the accessibility of NCD care by allowing patients to have all of their chronic conditions treated on the same day at their nearest health facility, notably without additional investment of human and financial resources. Currently, 6781 patients on antiretroviral therapy and 721 patients with NCDs are benefitting, including 379 with hypertension, 187 with asthma, 144 with epilepsy, and 76 with diabetes. Among the NCD patient population, 15.1% are HIV-positive. Success hinged largely on several factors, including clear leadership and staff ownership of their specific duties, and a well-defined and uniform patient flow process. Furthermore, deliberate and regular conversations about challenges allowed for constant iteration and improvement of processes. Moving forward, several tasks remain. We are refining the data management process to further consolidate medical records, along with integrating our tracking processes for clients who miss appointments. Additionally, we are exploring opportunities for
Background A project is a temporary endeavour undertaken to create a product or service. Projects are frequently used for the testing and development of new approaches in social work. Projects can receive grants from central, often national or international institutions, and allow for more...... experimentation than work placed within existing institutions. Discussion For socially marginalized groups who need continuing support and care, receiving help in a project means that the clients will have to be transferred to other services when the project ends. There is also a risk that clients will experience...... relating to continuity of services when serving vulnerable patients with a need for continuing care....
Full Text Available Background. Self-management support and team-based care are essential elements of the Chronic Care Model but are often limited by staff availability and reimbursement. Mobile phones are a promising platform for improving chronic care but there are few examples of successful health system implementation. Program Development. An iterative process of program design was built upon a pilot study and engaged multiple institutional stakeholders. Patients identified having a “human face” to the pilot program as essential. Stakeholders recognized the need to integrate the program with primary and specialty care but voiced concerns about competing demands on clinician time. Program Description. Nurse administrators at a university-affiliated health plan use automated text messaging to provide personalized self-management support for member patients with diabetes and facilitate care coordination with the primary care team. For example, when a patient texts a request to meet with a dietitian, a nurse-administrator coordinates with the primary care team to provide a referral. Conclusion. Our innovative program enables the existing health system to support a de novo care management program by leveraging mobile technology. The program supports self-management and team-based care in a way that we believe engages patients yet meets the limited availability of providers and needs of health plan administrators.
Abraham Aragones, MD, MSCI
Full Text Available IntroductionThe Patient Assessment of Chronic Illness Care (PACIC survey is a patient-centered instrument for evaluating the quality and patient-centeredness of chronic illness care received according to the Chronic Care Model paradigm. This study validates the Spanish translation of the PACIC in an urban, Spanish-speaking population.MethodsOne hundred Spanish-speaking patients with diabetes completed the translated PACIC and sociodemographic and cultural questionnaires. Test-retest reliability was assessed in a subset of 20 patients who completed the questionnaire 2 to 4 months later. Internal consistency was evaluated with Cronbach α. PACIC score and subscale associations with sociodemographic characteristics were examined.ResultsTest-retest reliability for the overall translated PACIC scale was 0.77. Scores were not associated with patient sociodemographic characteristics, including age, country of birth, years living in the United States, or education level (P >.05.ConclusionThe Spanish translation of the PACIC survey demonstrated high reliability, internal consistency, and test-retest reliability. Scores showed no association with sociodemographic or cultural characteristics. The Spanish version can reliably be used to assess care delivered according to the Chronic Care Model in a heterogeneous Spanish-speaking population.
Vrijhoef, Hubertus J.M.; Berbee, Rieneke; Wagner, Edward H.; Steuten, Lotte M.G.
Objective To identify the most appropriate generic instrument to measure experience and/or satisfaction of people receiving integrated chronic care. Background Health care is becoming more user-centred and, as a result, the experience of users of care and evaluation of their experience and/or satisfaction is taken more seriously. It is unclear to what extent existing instruments are appropriate in measuring the experience and/or satisfaction of people using integrated chronic care. Methods ...
DuGoff, Eva H.; Bandeen-Roche, Karen; Anderson, Gerard F.
Background: Continuity of care is a basic tenant of primary care practice. However, the evidence on the importance of continuity of care for older adults with complex conditions is mixed. Objective: To assess the relationship between measurement of continuity of care, number of chronic conditions, and health outcomes. Design: We analyzed data from a cohort of 1,600 US older adults with diabetes and ≥1 other chronic condition in a private Medicare health plan from July 2010 to December 2011. M...
Lukewich, Julia; Corbin, Renée; Elizabeth G VanDenKerkhof; Edge, Dana S.; Williamson, Tyler; Tranmer, Joan E.
Rationale, aims and objectives Given the increasing emphasis being placed on managing patients with chronic diseases within primary care, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive. This study aimed to identify, summarize and compare data collection tools that describe and measure organizational attributes used within the primary care setting worldwide. Methods Systematic search and r...